Citation Nr: 1334472 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-01 724 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for residuals of injury to the index, long, and ring fingers of the right hand other than scars. 2. Entitlement to service connection for a psychiatric disorder, to include depression, bipolar disorder, and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active duty from September 1977 to November 1979. This matter comes before the Board of Veterans' Appeals (Board) from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which in part denied service connection for PTSD and confirmed and continued a previous denial of service connection for the right hand disability. The right hand disability was originally denied in an April 2008 rating, but the RO reconsidered the matter prior to expiration of the appeal period following the receipt of additional evidence. In consideration of Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a service connection for a mental health disability claim encompasses all psychiatric disability shown/alleged) the issue of service connection for a psychiatric disability claimed as PTSD has been characterized to encompass any diagnosed psychiatric disability. The Veteran testified a videoconference hearing held before the undersigned Veterans Law Judge in November 2012. A transcript of the hearing is associated with electronic record. This matter was previously before the Board, and in a February 2013 decision the Board determined that the evidence before it showing right hand scarring, as well as orthopedic and neurological complaints, separated the issues to afford adjudication of a claim for service connection for residuals of injury to the right hand manifested as scars as separate from a claim for residuals of injury to the right hand other than the scars. The Board granted service connection for the scars and remanded the issue of a claim for residuals of injury to the right index, long, and ring fingers other than scars for further development. The issue of entitlement to service connection for a psychiatric disorder was also remanded. (The issue of entitlement to a right finger disorder other than scarring is addressed in the remand that follows the decision below.) FINDING OF FACT The Veteran does not have an acquired psychiatric disorder traceable to military service, including to any claimed in-service stressor. CONCLUSION OF LAW The Veteran does not have a psychiatric disability that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Board notes the provisions of the Veterans Claims Assistance Act of 2000 (VCAA); Pub. L. No. 106-475, 114 Stat. 2096 (2000). See 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5107 (West 200 & West Supp. 2013). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2013). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a) (West 2002 & West Supp. 2013); 38 C.F.R. § 3.159(b) (2013). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. 73 Fed. Reg. 23353 -56 (April 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the claimant to provide any evidence in the claimant's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The Board finds that all notification and development action needed to arrive at a decision as to the claim decided herein has been accomplished. Through a July 2008 notice letter, sent prior to the February 2009 rating, the RO notified the Veteran of the information and evidence needed to substantiate his claim. The RO additionally sent a follow-up notice in October 2008 requesting specific details to help VA verify any claimed in-service stressors. Following the Board's remand in February 2013, the Appeals Management Center (AMC) sent a letter in March 2013 again requesting the Veteran to provide details to assist the VA in stressor verification. The Board also finds that the February 2008 notice letter satisfied the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C. F.R. § 3.159(b) ). In the letter, the RO notified the Veteran that VA was responsible for obtaining relevant records from any Federal agency and that the RO would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Additionally, the notice letter requested the Veteran to submit medical evidence, opinions, statements, and treatment records regarding his disability. This letter also notified him of the general criteria for assigning disability ratings and effective dates. Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). There is no indication that any additional action is needed to comply with the duty to assist in connection with the issue decided. The Veteran's service medical records and Social Security Administration (SSA) records have been associated with the claims file, as have treatment records from the VA Medical Center. The Veteran has undergone a VA examination regarding his claim, the report of which is associated with the claims file. Significantly, neither the Veteran nor his representative has otherwise alleged that there are any outstanding medical records relevant to the Veteran's claim that yet need to be obtained. The Board finds no reason to remand the matter to attempt to obtain a more comprehensive stressor verification because the Veteran has not provided the information required to attempt verification of his alleged stressor. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that the duty to assist is not a one-way street). After he provided stressor information in August 2008 that was not adequate for verification purposes, he was sent a letter requesting he provide more specific details regarding his claimed stressors, and he failed to respond. A formal finding of lack of information required to verify stressors in connection with the PTSD claim was issued in November 2008 indicating that the information remained inadequate for stressor verification purposes. After the matter was remanded in February 2013, he was provided a letter in March 2013 again requesting he provide additional details of his claimed stressors to allow for further verification. He failed to respond to this letter. The Veteran has further been given the opportunity to submit evidence, and he and his representative have provided written argument in support of his claim. Neither the Veteran nor his representative has identified, and the record does not indicate, existing records pertinent to the claim decided herein that need to be obtained. II. Analysis The Veteran claims service connection is warranted for a psychiatric disorder, to include PTSD, as a result of his military service. The stressor triggering the PTSD is generally described as the Veteran witnessing a friend who hung himself while they were serving together in Japan. Later, at a July 2013 VA examination, he alleged an additional stressor during basic training of being made to march past the aftermath of an incident where a trainee had jumped to his death. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain conditions, such as a psychosis, will be presumed to have been incurred in service if manifested to a compensable degree within 1 year after service. 38 U.S.C.A. § 1112 ; 38 C.F.R. §§ 3.307 , 3.309. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see 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). Entitlement to service connection for PTSD requires medical evidence diagnosing PTSD in accordance with the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f) ; 4.125(a). Where the claimed stressor is not related to combat, the Veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the Veteran's account as to the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) ; 38 C.F.R. § 3.304(d), (f) (2012); Cohen v. Brown, 10 Vet. App. 128 (1997). Evidence denoting participation in combat includes award of decorations such as the Combat Action Ribbon, Combat Infantryman Badge (CIB), Purple Heart Medal, and decorations such as the Bronze Star Medal that have been awarded with a Combat "V" device. In this case, the Veteran's DD Form 214 shows that he did not receive any decorations or medals denoting participation in combat. Indeed, the Veteran has not claimed participation in combat. Where VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the veteran's account as to the occurrence of the claimed stressor. See 38 U.S.C.A. § 1154(b) ; 38 C.F.R. § 3.304(d), (f); Cohen v. Brown, 10 Vet. App. 128 (1997). With regards to the corroboration of stressors, the Board observes a recent amendment to 38 C.F.R. § 3.304 concerning stressors based on a veteran's "fear of hostile military or terrorist activity." This provision is not applicable in this matter as the evidence neither shows, and the Veteran does not allege any stressors related to fear of hostile military or terrorist activity. Likewise as he has not alleged PTSD stressors based on personal assault, the provisions of VA Adjudication Procedure Manual M21 pertaining to stressor verification based on such assaults are not for application. Service treatment records reveal that there was no psychiatric abnormality noted at a January 1977 entrance examination, with the accompanying report of medical history negative for any complaints of a possible psychiatric problem, such as frequent trouble sleeping, depression or excess worry, loss of memory/amnesia, nervous trouble of any sort or periods of unconsciousness. In June 1979, the Veteran was seen for a history of episodic offenses while drinking. He was referred to the doctor by a battalion alcohol rehabilitation counselor. The Veteran stated that he currently did not drink but prior to that time, he had imbibed 3 mixed drinks and 3 beers. He denied blackouts, delirium tremens or alcohol withdrawal seizures. It was noted that he drank prior to service, but had no previous problem with authorities. The drinking occasionally affected his work abilities. He was noted to have abstained over the past week. Antabuse was recommended after further testing (SMA-12) was done. A July 1979 report from the USMC Challenge and Development Center noted the Veteran initially entered the Center as very quiet, sullen and withdrawn, and initially did not display any motivation for treatment. He consistently claimed the Marine Corps drove him to drinking. During the course of treatment, he gradually began to focus on treatment and began to work diligently on getting rid of his alcohol dependency. At the same time his personal appearance and attitude began to steadily improve. He made a commitment to abstain from alcohol and better his performance. It was felt that with guidance and counseling by his commanding officer, that he would become a very productive Marine. It was recommended that he be placed on Antabuse and mandatory AA attendance. During the latter part of treatment his appearance and attitude were excellent and he was expected to remain so on his return to duty. No mental disorder was diagnosed. On separation examination in October 1979, he was psychiatrically normal, with the accompanying report of medical history negative for any complaints of a possible psychiatric problem, such as frequent trouble sleeping, depression or excess worry, loss of memory/amnesia, nervous trouble of any sort or periods of unconsciousness. There is no evidence of psychiatric or substance abuse treatment prior to 2007, when in May 2007 the Veteran requested mental health treatment for complaints of using crack cocaine after he became depressed following a divorce of his marriage. He reported using it intermittently for 5 years, but it had increased to every other day. He also complained of problems falling asleep, poor appetite and significant weight loss. His energy was low and he had a depressed mood. This was his first attempt at a rehabilitation program. He denied any past treatment for substance abuse or mental health issues. He reported that he began smoking at age 12 after his father was killed in a motor vehicle accident. He was raised with 3 brothers by his mother. Mental status examination yielded no remarkable findings and his PTSD screen was negative. He was diagnosed with cocaine dependence, rule out substance abuse induced depression. Axis II diagnosis was deferred. Other treatment records during this inpatient addiction treatment in May 2007 revealed a similar history and findings. His work history was of last working in 2006 at Carl Tubing, which job he lost due to failing a urine drug test. He denied any stressors. He continued with inpatient rehabilitation for his addiction through June and July 2007, with mental status findings and history noted to include depression or depressed mood. He also had trouble sleeping noted in the records in 2007, along with complaints of low energy and little or no motivation. He continued to be assessed with cocaine dependence, alcohol abuse, rule out substance abuse disorder. The PTSD criteria were not met on screening. Similar symptoms persisted in August 2007, but he reported having insomnia and dreams, only sleeping 2-3 hours per night. He was noted to have a depressed mood with congruent affect, but no other significant findings on mental status examination. The assessment remained unchanged. Another mental health treatment note from the same month described continued difficulty sleeping due to nightmares about seeing another soldier hang himself. He had not had significant improvement with the use of Trazadone. He was assessed with history of polysubstance abuse presenting with continued difficulties with nightmares. He was placed in the domiciliary program, and an October 2007 compensated work therapy (CWT) intake report gave an Axis I diagnosis of cocaine dependence, rule out substance abuse, depression and alcohol abuse. He gave a work history of last working at a plastic factory in 2007, losing this job due to substance abuse. He continued in the CWT and domiciliary program throughout the end of 2007 with records focusing on his addiction recovery and CWT. A January 2007 mental health record disclosed persistent anxiety, nightmares and disturbed sleep in spite of his current medication regimen. He was assessed with depression not otherwise specified (NOS) with polysubstance abuse in remission. A March 2008 mental health attending note revealed complaints of mood swings, sleeping only 5-6 hours a night and nightmares every other night about someone who hung himself in the military. He inquired about why he did not have a diagnosis of PTSD despite being told he had symptoms of it. He was noted to report nightmares, "visions" of people trying to kill himself. He said he could not stand to work around people, loud noises or crowds. He tended to isolate himself. He wanted to get diagnosed with and treated for PTSD. Mental status examination was significant for a mood depressed at times and mildly blunted affect. He was assessed with history of polysubstance use and depression, presenting with continued depression. The medical provider was concerned about his asking about PTSD as review of his chart showed no such diagnosis. Nonetheless he did report some symptoms suggestive for possible PTSD. An April 2008 PTSD screen disclosed complaints of recurring nightmares of seeing a friend who hung himself in Japan. The Veteran reported a recent exacerbation of these after another patient told him "the best thing for you is a noose around your neck." The poor sleep and nightmares were every other night. He described the stressor incident as taking place in Okinawa and he was walking through a large building when he came upon his friend hanging. His initial reaction was of disbelief, and he "broke down." The Japanese authorities cut the body down in a manner he found callous, allowing the body to drop to the floor. The Veteran reported a crowd watching the body being cut down. He never sought help in the service, but was eventually sent to "lockdown" for alcohol treatment. He reported being "busted" from E4 to E1 for alcohol problems. For the first time he reported a history of having lost a brother in childhood, when he was 5 and reported he lost his father when he was 6. Both were killed in car accidents. His mother was said to have raised him along with 3 surviving brothers. He also reported a history of a suicide attempt by overdose in the 1980s when he was going through a divorce. The format of a 12-week PTSD group was discussed. VA treatment notes revealed that along with continued participation in transitional housing programs and other treatments, he was in the 12-week PTSD program in June and July of 2008. A July 2008 mental health note revealed ongoing complaints of nightmares of finding another person who hung himself, and ongoing difficulties sleeping. He was noted to inquire about a letter stating he had PTSD. Following mental status examination that was remarkable primarily for evidence of a slightly depressed mood and slightly blunted affect, he was assessed with history of polysubstance abuse with some ongoing sleep difficulties due to nightmares. It was noted that learning PTSD coping skills had been helpful. A September 2008 mental health record noted the Veteran's difficulty with nightmares were reported to happen most nights and were flashbacks to his discovering his friend hanging from the rafters and the authorities cutting the body down. He recalled hearing the "thud" of the body. He also now reported daytime flashbacks. He discussed other losses in his life, including his father who died when he was 5 and his uncle who died 3 years ago. Notably absent from this report was any history of a brother dying in childhood. He reported bad anger, sleep difficulties, arguing, cursing, poor appetite, loss of libido and depressed feelings. He described having 3 brothers who were doing well. He was the only one who was not well, and this was dated to the hanging. The therapist raised the possibility of anger towards the friend who died. Mental status examination revealed he presented well, but was quick to admit he had a difficult time speaking about what was on his mind due to trust issues. His mood was depressed, but he had some spontaneity. The impression was major depression, PTSD, and cocaine and alcohol addiction in remission. Also in October 2008, in his first therapy session he reported several issues that included the past suicide of his friend, but also reported trust issues he attributed to several losses, including his father's "giving up" after a serious car accident when he was 8 years old, and his brother's death after a car accident, also when the Veteran was 8 years old. He also discussed the recent death of a close uncle. A September 2008 stressor statement was submitted by the Veteran and related a history of his trying to persuade a Marine he did not know from committing suicide by hanging himself. He personally felt that he failed. In April he was threatened to be hanged by another patient described as a "Klan" member in the domiciliary. He was noted to be enrolled in a PTSD class and his mental posture psychologically was "avoidance" conducive with PTSD sufferers. He was noted to draw a blank when asked about the situation in Japan. The treatment records from November and December 2008 revealed the Veteran was admitted to PHLAG group with admissions of PTSD, Depression and a past history of alcohol and drug dependency. In a November 2008 individual therapy record, he continued to report nightmares that were more frequent, but now also said he hears voices when awake. He said he had a history of auditory hallucinations but had never previously been that strong. In a December 2008 mental health interim note, he was reported as having a history of substance dependence, Bipolar I, unemployment and lack of housing. Another December 2008 record revealed the Veteran to again describe in-service trauma of finding his friend hanging from the rafters, saying this took place while he was with a group in formation. He said they were forced to wait 20 minutes until the Japanese authorities cleared them and cut the body down. He said that he never forgot the sound it made. He claimed that he began drinking after this incident and was sent to a 30-day program and took Antabuse, which did not help. He claimed this led to his use of marijuana and crack. The symptoms never left him and he endorsed all the symptoms of PTSD. These included anxiety related to the trauma, avoidance of the trauma related stimuli, flashbacks, intrusive thoughts, exaggerated startle response, isolation/distance from loved ones, intense guilt, nightmares of trauma, emotional numbing, anger control problems and shortened sense of the future. Treatment records from early 2009 addressed issues surrounding his being discharged from a VA transitional housing program due to a positive test for barbiturates in January 2009, with the medical personnel eventually finding that he had taken the medication causing the positive finding for valid pain control reasons rather for substance abuse purposes. Social Security Administration records include an October 2008 disability evaluation that revealed the Veteran's chief complaints at the time were of "depression and manic depression." He described how he could be up one minute, and the next minute his whole world is falling apart. He said he felt depressed all the time and that his mood worsens as the day progressed. He reported trouble sleeping and poor appetite with a loss of 20 pounds over the past 6 months. He reported having been diagnosed with PTSD apparently by the VA hospital and referred to an event in 1978 in which "my friend hung himself" and the police cut the rope and let the body hit the ground like a block of ice. He stated that he had 3 brothers, with one who died when the Veteran was about 8 years old. His father was said to have died when he was 9. He was noted to have used drugs on and off for 15 years with cocaine regularly for the past 6-7 years and completion of residential rehabilitation in 2007. Mental status exam was unremarkable except for mild to moderately depressed mood by observation and a restricted affect. He was assessed with major depressive disorder, recurrent, moderate (depressed mood, sleep problems, low energy). A consultant's note dated in October 2008 noted the Veteran to allege bipolar disorder and PTSD as well as difficulty concentrating. On mental status examination vague delusional thought was present. He heard voices that told him what to do and not do. VA treatment records from 2012 to 2013 show that his Axis I diagnosis was repeatedly determined by mental health clinic to be bipolar II disorder, cocaine dependence in sustained full remission, alcohol dependence and nicotine dependence. Axis II was repeatedly deferred. The records revealed that in May 2012 he reported a history of sobriety from 2007 to 2011 but was now drinking up to 18 drinks a day and was worried if he continued he might restart cocaine. He desired to embrace sobriety. In July 2012 he presented for rehabilitation for drinking, with a psychosocial assessment noting that his 3 brothers were still living and gave a history of his father dying when he was 11 years old. He was noted to have a diagnoses that included bipolar disorder and PTSD and had significant alcohol and cocaine abuse. He reported occasional auditory hallucinations. He was discharged from the substance abuse treatment later in August after successfully completing the program. He continued with mental health treatment with a November 2012 record discussing his difficulties trusting people after his father died and his friend hung himself, and he reported ruminative images of the Japanese police cutting his friend's body down. A past history of auditory hallucinations and flashbacks associated with his friend's death was also noted. Issues surrounding his friend's death were addressed in January 2013 and February mental health notes that revealed continued guilt about the death of his friend by suicide. The Veteran's November 2012 hearing testimony again repeated his alleged stressor of his friend having hung himself while he and the Veteran were stationed in Okinawa, Japan at Camp Schwab. He could not recall the date the incident took place other than in Springtime of 1978. He described having witnessed his friend's body hanging while in formation, and indicated that he witnessed the Japanese authorities cut the body down and it exploded when it hit the ground. He described the friend as being in a different unit and indicated he got to know him when he was assigned to drive an AMTRAK vehicle. He currently described symptoms such as nightmares and sleep problems. Transcript from 1-8. The report of a July 2013 VA examination for PTSD included a review of the claims folder (including electronic record) and examination of the Veteran. The examiner determined that the Veteran's current diagnosis was bipolar disorder, alcohol dependence in early partial remission and cocaine dependence in full remission. PTSD was not diagnosed. The mental status examination revealed the Veteran to be cooperative, with good rapport, had normal speech and eye contact. His mood was described as pretty good, with congruent affect. There was no evidence of psychotic thought or other major thought disorder. He was alert and oriented times 4. His memory was generally intact and no problems were noted with his attention and concentration. He had adequate comprehension and understanding, but had poor abstraction of proverbs. His judgment and insight appeared acceptable. The Veteran gave a history of his father and a brother dying in motor vehicle accidents when the Veteran was 6 years old. He indicated that he lived with his mother and was looked after by uncles. He denied a history of abuse as a child and described a good relationship with his mother. He described pre-military life as normal, with many friends. He described his post-military life as going into a spiral with fewer friends, and generally just connected with family members and his significant other. He described that he drank heavily in the military after his friend hung himself, resulting in his being "busted down in rank" prior to discharge. He reported that he started drinking in the military when he got out of boot camp and was okay until he got demoted following a DWI and being demoted. Then his friend hung himself and he then was drinking and smoking marijuana about every other day, but with no other drug use in service. He reported that, after service, he abused alcohol, marijuana and cocaine from 1985 to 2007 and after attending rehabilitation in 2007 he relapsed with alcohol a couple of times but not with drug use. He attended a rehabilitation program for 28 days last year. Regarding pre-service sentinel events, the Veteran noted the deaths of his father and his brother in motor vehicle accidents when he was 5. He said this was traumatic because his uncles apparently pulled his brother from the car and he remembered seeing blood on their shirts, and re-experienced the memory of his brother's death when some of his military stressors are triggered. The Veteran described his in-service stressors as first, the worst traumatic life event involving his best friend (S. J.) who hung himself in Japan. The Veteran said that while in formation, he witnessed someone hanging, and the officers called Japanese authorities, who cut him down. He described the body as hanging 5 stories high and "exploded" when it hit the ground. He said his initial reaction was that he cried and felt guilty and remorseful. He now reported nightmares, distress and physical reaction to reminders, with triggers including horror movies. The next in-service stressor was described as happening in boot camp, after a trainee jumped out a window and the drill instructor marched the whole platoon around where it happened, and he saw brains. He said that he was reminded of seeing his uncles' bloody shirts after the accident and he felt sad. He used to have intrusive thoughts all the time but medication was helping. He now had nightmares about 2-3 times a week, and avoided reminders. He reported intense distress at exposure cues of feeling "sad and depressed" and physical reactivity, but no guilt. The examiner determined that these stressors failed to meet criterion A for a stressor adequate to support a diagnosis of PTSD. In so finding, the examiner called into question the Veteran's credibility, as well as a lengthy history of substance abuse noted. The examiner pointed to conflicting histories throughout the medical records. These included various inconsistencies reported throughout the record including regarding his employment history as to when and where he last worked, the history reported by the Veteran regarding the onset of his substance abuse, the history surrounding the inservice stressor of the death of his friend, and even the history regarding the preservice death of his brother. Among the inconsistencies noted, the examiner noted that regarding the stressor of the hanging, the Veteran's description of the incident and relationship between him and the individual who hung himself greatly varied, with the Veteran describing the stressor as trying to persuade a Marine he did not know from committing suicide by hanging, (as reported in the stressor statement received in September 2008). Now in this examination, the Veteran described the individual as his best friend. The second stressor that he described of the suicide jumper in boot camp was noted to have been absent in the records or in his claim. Similarly, inconsistencies surrounding his brother's death prior to service were noted, with the Veteran noted in a November 2011 treatment note describing the brother, who was one of 3 brothers, dying at age 5, while no mention of the brother's death was mentioned in a March 2010 psychosocial assessment. Elsewhere he was noted to report all his brothers as alive in November 2008. Inconsistencies in his substance abuse history were noted to have been shown when in a December 2008 mental health attending note, he reported he started drinking after his friend's death in the service, but on the current examination, he reported a history of his drinking starting after he got out of boot camp, and then his life started spiraling down, he got a DWI then went AWOL for 30 days, and then his best friend committed suicide within 6 months. Thus, he disclosed his substance abuse problems began prior to the friend's suicide. Additionally, the examiner performed testing, which included a test for response bias specifically related to PTSD symptoms to assess the Veteran's self reporting credibility. Results from this testing indicated that his performance was not consistent with having PTSD, but was consistent with the test performance of someone simulating symptoms of PTSD. As a result there was a reason to suspect symptom exaggeration and a response style indicative of attempts to portray himself as worse off than he may actually be, especially regarding PTSD symptoms. The examiner noted that the Veteran's treatment records in the CPRS file showed a history of diagnosis and treatment for PTSD but speculated that the providers were not likely aware of credibility issues in his reporting, as they did not have access to his claims file. The examiner noted that the Veteran has acknowledged having a history of bipolar disorder, with numerous records in the CPRS showing a diagnosis and treatment for bipolar II disorder. His symptoms at the time of the current evaluation were consistent with the DSM IV TR criteria for bipolar II disorder. The examiner noted that the bipolar II disorder was diagnosed at least 20 years after military service, and thus was not the likely the result of service. Additionally, the Veteran was noted to report a history consistent with alcohol dependence in early partial remission and cocaine dependence. Having reviewed the evidence, the Board finds that the preponderance of the evidence is against the claim. The Board gives the greatest weight to the findings from the VA examiner who conducted the July 2013 VA examination and found that the criteria for a diagnosis of PTSD are not met, and determined that the diagnosed disorder, bipolar II was not the likely result of service. This examination included obtaining a detailed history, examination (including testing), claims file review and comprehensive explanations of the rationale for determining that the Veteran had not met the criteria for a diagnosis of PTSD. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). In providing the rationale, the examiner noted the bipolar disorder was not diagnosed until 20 years after service. The examiner also found great issues of credibility, pointing out numerous inconsistencies involving the Veteran's reported histories of the stressor of the individual who died by hanging, who was variously described as either a stranger, a friend or a best friend. Additional inconsistencies were also variously shown in other aspects of the Veteran's life, most significantly the inconsistent histories regarding the alleged death of brother in childhood. Evidence of these inconsistencies is shown in the various records in the claims file and electronic record. Such inconsistencies and the findings from testing in the July 2013 VA examination also called into question his credibility. The claimed stressor of the friend's suicide by hanging has not been confirmed by official channels. Regarding the claimed stressor of the individual jumping out of the window during basic, this was not reported until the July 2013 examination. Thus, the Board does not find there to be a credible stressor to support the diagnosis of PTSD. Despite being asked for detailed information regarding his claimed stressors, to specifically include the approximate date of the alleged stressful events, the Veteran provided no additional information regarding his stressor so as to enable VA to submit a request for verification of the alleged stressor. See Wood, supra. Regarding other psychiatric disorders, including bipolar disorder and depression, as pointed out by the examiner in the July 2013 examination, the Veteran was determined to have a diagnosis of bipolar disorder, and did not have this diagnosis until 20 years after service, and a nexus between this disorder has not been provided by the medical evidence. The examiner did not give a diagnosis of depression, and this is shown not to have been a diagnosis in the more recent records from 2012-2013, but appears rather to be a symptom of the diagnosed bipolar disorder, shown on mental status examination. In the earlier records diagnosing major depressive disorder up through 2008, there is no evidence of a nexus between the major depressive disorder and service shown. The Board gives lesser weight to the medical evidence that suggests a diagnosis of PTSD related to service based on there being a lack of a verified stressor to support such a diagnosis. The Board acknowledges that claims folder review is not a requirement for medical opinions, and that a medical opinion may not be discounted solely because the opining clinician did not conduct such a review. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, the findings of PTSD appeared to be based on interviews without diagnostic testing or consideration of the Veteran's history as found in the record. Again the Veteran's credibility issues weigh against finding that a diagnosis of PTSD exists based on the stressors cited by him. Regarding the diagnosed disorders of alcohol abuse and cocaine dependence, the Board does acknowledge that the Veteran was treated for alcohol issues during active duty. However service connection is not warranted for primary alcohol abuse, or any disabilities resulting from such alcohol issues. See 38 C.F.R. § 3.301 providing that no compensation shall be paid if the disability resulting from injury or disease in service is a result of a veteran's willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. §§ 105, 1131. Direct service connection may be granted only when a disability was incurred or aggravated in the line of duty, and not the result of a veteran's willful misconduct or, for claims filed after October 31, 1990, the result of his abuse of alcohol or drugs. 38 C.F.R. § 3.301. There is a very limited exception to this general rule, when the converse occurs, that is, when a disability instead causes a veteran to abuse drugs or alcohol - such as to relieve, mask or alleviate the symptoms associated with a that disability. In Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the Federal Circuit held that compensation could not be awarded pursuant to 38 U.S.C.A. § 1110 and 38 C.F.R. § 105(a) either for a primary alcohol/drug abuse disability incurred during service or for any secondary disability that resulted from primary alcohol/drug abuse during service. Id. at 1376. However, the Federal Circuit further held that there can be service connection for compensation for an alcohol/drug abuse disability acquired as secondary to, or as a symptom of, a non-willful misconduct, service-connected disability. But in further clarifying this, the Federal Circuit explained that veterans may only recover if they can "adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder." Id. at 1381. An award of compensation on such a basis would only result "where there is clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a veteran's primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing." Id. There is no evidence of any primary service connected disability shown to have caused the alcohol or drug abuse disability; the evidence does not show that the Veteran had any psychiatric disorder in service. Thus the exception does not apply in this instance. In sum, the preponderance of the evidence is against the claim of service connection for a psychiatric disorder, including PTSD, depression, or bipolar disorder,. The evidence does not show that any such disability began in service or resulted from any incident in service. There is no evidence of a psychosis having manifested within the first post-service year. There is no other basis, either shown by the evidence or otherwise alleged, upon which to warrant a grant for this service connection claim. ORDER Service connection for a psychiatric disorder, to include depression, bipolar disorder, and posttraumatic stress disorder (PTSD) is denied. REMAND Once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr, 21 Vet. App. at 311; see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). A July 2013 VA neurological evaluation for the right fingers disability is incomplete. Although the examiner suggested that the Veteran's clinical examination was negative for peripheral nerve involvement, the examiner also indicated that he would be scheduling the Veteran for electromyograph (EMG) studies and would fax the results when available. Thus, it appears that the examiner deemed such testing necessary in order to more clearly determine the presence or absence of any neurological disability affecting the fingers. Review of the claims file and electronic record does not disclose that such testing was done or that a report of any completed testing was obtained. Thereafter, an opinion was obtained from an August 2013 VA physician who reviewed the claims folder and based an opinion in part on the findings from this incomplete information. Without obtaining the EMG test results and getting a follow-up opinion, the Board is left to rely on its own opinion, which the Board is precluded from doing. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board may only consider independent medical evidence and may not substitute its own medical opinion.) The Board finds that further evidentiary development is required. See 38 C.F.R. § 4.2 (2013) (providing that where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Accordingly, remand is required. The case is REMANDED for the following action: 1. Obtain the results of EMG testing ordered by the July 2013 physician's assistant. Thereafter, refer the case to the July 2013 examiner. The examiner should be asked to clarify whether the Veteran has any current, chronic neurological disorder affecting the right hand. If so, is it at least as likely as not that any current neurological disorder is traceable to military service; or was any such disorder manifested within one year of separation from military service? In answering these questions, the examiner must consider all service treatment records as well as any and all post-service medical records, to include any results from EMG or other testing obtained. The examiner must also consider any lay evidence that has been provided by the Veteran regarding his right hand and finger complaints, as well as his lay evidence regarding his symptoms subsequent to injuries to this hand in service. Any opinion offered should include an explanation based on sound medical principles. If any of the Veteran's theories regarding a relationship to service are rejected, the medical reasons for rejecting any such theory should be set forth in detail. (If the examiner is no longer available, or concludes that an examination is required to provide the required opinions, another examination should be scheduled.) If an examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The agency of original jurisdiction (AOJ) should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 2. The AOJ must ensure that all medical examination reports and opinion reports comply with this remand and the questions presented in the request. If any report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 3. After undertaking any other development deemed appropriate, the AOJ should re-adjudicate the issue remaining on appeal. If the benefit sought is not granted, the Veteran should be furnished with a supplemental statement of the case (SSOC) and afforded an opportunity to respond before the record is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs