Citation Nr: 1752488 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 09-48 509 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. J. Tang, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from September 2003 to February 2008. He received decorations including the Combat Action Badge and the Iraq Campaign Medal. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). All documents on the Virtual VA paperless claims processing system and the Veterans Benefits Management System have been reviewed, including the transcript of the July 2016 Board hearing before the undersigned Veterans Law Judge. In September 2016, the Board remanded the claim for further development, and the case is again before the Board for further appellate proceedings. FINDING OF FACT The Veteran does not currently have PTSD that is distinct and separate from his already service-connected panic disorder, and he has not had such a separately diagnosed disorder during the pendency of the claim. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Compliance with Prior Remand In September 2016, the Board remanded the case and directed the AOJ to obtain updated VA treatment records, and the AOJ did so. The Board also directed the AOJ to obtain an addendum medical opinion to determine the nature and etiology of PTSD, and the AOJ did so. The examiner provided the requested information. The claim was then readjudicated in a supplemental statement of the case. For these reasons, the Board's prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed.Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection A Veteran is entitled to VA disability compensation for service connection if the facts establish that a disability resulted from disease or injury incurred in the line of duty or for aggravation of a preexisting disease or injury in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. The Veteran contends that he has a separate psychiatric disorder of PTSD that is distinct from his service-connected panic disorder. The Veteran contends that his PTSD is related to the same stressors that formed the basis for the grant of panic disorder, namely in-service combat stressors. The Veteran originally claimed entitlement to service connection for anxiety, depression, and PTSD. The October 2008 rating decision shows that the AOJ granted service connection for panic disorder (claimed as anxiety), and separately denied service connection for PTSD and depression. The Veteran submitted a notice of disagreement for the denial of service connection for PTSD and depression, but the Veteran limited his Form 9 to service connection for PTSD. Thus, the issue before the Board is limited to the matter of entitlement to service connection for PTSD. Here, the preponderance of the evidence is against finding that the Veteran has had a separately diagnosable disability of PTSD that is independent from the Veteran's service-connected panic disorder. The Board acknowledges that the Veteran has some medical training, as he is a registered nurse. However, there is no indication that he has expertise or training in the field of mental health, and therefore his opinion that he has a diagnosed disorder of PTSD separate from his panic disorder has little probative value. The Veteran argues that he received a diagnosis PTSD from his treating VA psychiatrist, Dr. M. S. See December 2009 Form 9; July 2016 Board hearing. However, the VA treatment records, such as a February 2009 treatment record, show that the Veteran's diagnosis of PTSD was initially rendered by a licensed social worker. This diagnosis of PTSD was rendered during a social work appointment, and the Veteran was apparently not seen by Dr. M. S. that day. The VA treatment records show that later in February 2009, Dr. M. S. saw the Veteran and the diagnosis was "panic disorder, rule out PTSD." The VA treatment records, to include a June 2009 record, reflects that it was a social worker who informed the Veteran that he met the criteria for a diagnosis of PTSD. The VA treatment records show social workers continued the assessments of PTSD. However, there is no indication that the Veteran's treating VA psychiatrist, Dr. M. S., confirmed the diagnosis of PTSD, and in a May 2011 VA treatment record, Dr. M. S. appears to have ruled out PTSD, as he noted the assessment of PTSD rendered by the social worker, but Dr. M. S. diagnosed the Veteran with only panic disorder that day. In VA treatment records thereafter, Dr. M. S. recurrently reiterates his diagnosis of only panic disorder. Given this evidence, it appears that the Veteran's only confirmed diagnosis of PTSD was rendered by social workers. Though social workers are medical professionals who have medical expertise and training in mental health, they do not receive the same level of medical training and do not have the same level of medical knowledge as psychologists or psychiatrists. Thus, the diagnosis of PTSD as separate from his panic disorder, rendered by social workers, have some probative value, but not high probative value. On the other hand, the diagnoses and opinion regarding the nature of the Veteran's psychiatric disorder rendered by the VA psychiatrist and VA psychologists after VA examination in this case have high probative value, as they rendered their diagnoses of the Veteran's psychiatric disability based on their extensive medical expertise and training in mental health and on examination of the Veteran. Further, the VA psychiatric examiners in this case rendered opinions that have particularly high probative value, as they based their opinions on review of the Veteran's claims file and medical history, and on the Veteran's subjective history. In particular, the March 2017 VA examination report, discussed below, has very high probative value, as the examiner reviewed the entire file and examined the Veteran prior to rendering his opinion. The opinions by these VA examiners that the Veteran has not had diagnosable PTSD during the appeal period outweigh above-discussed assessments of PTSD rendered by social workers. Here, on VA examination in May 2008, the VA psychiatrist, Dr. R., noted the Veteran's reported in-service stressors in combat. However, Dr. R. opined that the Veteran does not meet the DSM criteria for PTSD. Dr. R. stated that thought he Veteran's current psychiatric symptoms are linked to his experiences in Iraq, he meets only the criteria for panic disorder with adjustment disorder with mixed disturbance of emotion and conduct. On VA examination in October 2016, VA psychologist, Dr. C. R., opined that the Veteran is continuing to experience symptoms of panic disorder along with secondary depressive symptoms. Dr. C. R. stated that with respect to the question of a possible PTSD diagnosis, he could not draw a conclusion and recommended a follow up PTSD examination. Thus, the Veteran was afforded a VA examination in May 2017 for PTSD by a VA psychologist, Dr. D, who opined that the Veteran has no history of PTSD and does not currently have PTSD. Dr. D. stated that he reviewed the Veteran's extensive clinical treatment records. He opined that a diagnosis of panic disorder is more appropriate. He explained that while there may be a past diagnosis of PTSD, it is important to keep in mind that while someone may have historically met the diagnostic criteria for PTSD, PTSD is not a static diagnoses/condition, the symptoms wax and wane over time with the large majority of individuals having a significant resolution/decrease in symptomatology over time, this is the natural progression of PTSD. Dr. D. explained that in fact, a wide range of clinical literature over the years has shown that the great majority of persons exposed to Criteria A stressors, including combat Veterans, do not go on to develop full or chronic PTSD. Dr. D. explained that a more typical pattern is immediate symptoms that resolve to baseline or near baseline functioning over a period of time. Dr. D. stated that this Veteran meets this pattern and falls in the majority of those that do not have PTSD despite exposure to Criteria A stressor. Dr. D. stated that this assessment does not minimize or dismiss the events he experienced in service to our country and this service should be honored and appreciated. Dr. D. stated that, however, this Veteran appears to have had the resiliency and strength to recover from that trauma experience and has not developed full or chronic symptoms of PTSD. Dr. D. added in an opinion that the Veteran has been displaying symptoms of panic disorder since as early as March 2008. On review, and in light of the May 2017 VA examination, the preponderance of the competent and probative evidence is against a finding that PTSD independent from panic disorder existed at the time the claim was filed or at any time during the pendency of the claim on appeal. Further, as discussed above, the Veteran's treating psychiatrist declined to render a diagnosis of PTSD, and it appears that Dr. M. S. ruled out the diagnosis of PTSD. Thus, the claimed present disability PTSD is not shown, and service connection for the same is not warranted. 38 C.F.R. § 3.303; McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Board notes that the Veteran's service-connected panic disorder and his symptoms thereof, has been granted service connection and evaluated as effective during the entire period on appeal. ORDER Entitlement to service connection for posttraumatic stress disorder is denied. ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs