Citation Nr: 1801318 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 17-34 448 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for trichotillomania, to include as secondary to an acquired psychiatric disorder to include PTSD. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD B. J. Komins, Associate Counsel INTRODUCTION The Veteran had active service from May 2000 to October 2003. The Veteran also served in the US Army National Guard from September 2007 to November 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal on a July 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In Clemons v. Shinseki, 23 Vet, App. 1 (2009), the United States Court of Appeals for Veterans Claims (Court) noted that the Board should consider alternative current disorders within the scope of the filed claim. Id. In light of Clemons, the Board has framed the issue as entitlement to service connection for PTSD as entitlement to service connection for an acquired psychiatric disorder to include PTSD. The Board notes that the evidence of record has raised the issue of entitlement to service connection for trichotillomania, to include as secondary to an acquired psychiatric disorder to include PTSD. Therefore, the issue is so reflected on the title page. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2014). FINDINGS OF FACT 1. An acquired psychiatric disorder, to include PTSD was not manifest during service and is not related to service. 2. The Veteran does not have trichotillomania. 3. The Veteran does not have trichotillomania and therefore it is not secondary (caused or aggravated) by a service connected disease or injury. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include PTSD was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103A, 5107 (2014); 38 C.F.R. §§ 3.303 (2017). 2. Trichotillomania was not incurred in or aggravated by service and is not proximately due to or a result by a service-connected disease or injury. 38 U.S.C. § 1110 (2014); 38 C.F.R. §§ 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Duty to Notify and Assist VA has a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2017). To the extent these claims were filed in a December 2015 VA Form 21-526EZ, Fully Developed Claim, no discussion is necessary as to the duty to notify. VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claim. See 38 U.S.C. § 5102(a)(1) (2014); 38 C.F.R. § 3.159(c) (2017). Service treatment records (STRs), post-service VA treatment records, and lay statements have been associated with the claims file. VA must provide a medical examination or obtain a medical opinion when necessary to decide a claim. See 38 U.S.C. § 5102A(d) (2014); 38 C.F.R. § 3.159(c)(4) (2017). The Veteran was afforded multiple VA examinations during the pendency of her claim. The Board finds that an additional medical examination or opinion is not necessary to decide the Veteran's claim. See Barr v. Nicholson, 12 Vet. App. 303, 311 (2007). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 C.F.R. § 3.303(d) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Under 38 U.S.C. § 1154(b) (2014), the evidentiary burden for combat veterans with respect to evidence of in-service incurrence or aggravation of an injury or disease is reduced. See Collette v. Brown, 82 F.3d 389, 392 (Fed.Cir.1996). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a)-(b) (2017). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury 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 nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310 (a)-(b) (2017). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA will consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to a determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2014); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight." It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Acquired Psychiatric Disorder and Trichotillomania The Veteran contends that she is entitled to service connection for an acquired psychiatric disorder, to include PTSD as well as service connection for trichotillomania. Alternatively, the Veteran contends that trichotillomania was caused or aggravated by an acquired psychiatric disorder to include PTSD. Review of the Veteran's personnel records reveal that active service occurred in Iraq and Kuwait, therefore the Board concedes that she experienced fear of a hostile military or terrorist activity. See 38 C.F.R. § 3.304 (f)(3) (2017). However, these records do not show that the Veteran engaged in combat, therefore 38 U.S.C. § 1154(b) (2014) does not apply in this case. A review of the Veteran's STRs shows that the Veteran reported in September 2003 that she did not feel down, depressed, or hopeless much of the time; further she did not indicate that she had little interest or derive little pleasure in doing things. In a Report of Medical Examination during the same month, she indicated that her psychiatric state had not been evaluated. However, the Veteran did report in a September 2003 Report of Medical History that she had experienced anxiety; had trouble sleeping; had received counseling; experienced depression; had been treated for depression; had attempted suicide; and used illegal drugs or abused prescription drugs. The record of evidence shows that this Report of Medical History was a component of the Veteran's examination prior to her general discharge for misconduct, which included two positive drug tests. The Veteran's STRs do not provide impressions of obsessive compulsive disorder (OCD) or PTSD. A review of records obtained from the Defense Personnel Retrieval System (DPRIS) includes the Veteran's September 2003 Department of the Army Elimination Packet. In addition to the Report of Medical History, noted above, the Packet includes a Report of Mental Status Evaluation. In this evaluation, a military physician reported that the Veteran's behavior was normal; she exhibited full alertness and orientation; her thinking process was clear; her thought content was normal; and her memory was good. He also opined that the Veteran had the mental capacity to understand and participate in discharge proceedings, exhibiting mental responsibility and retention requirements. Based on this evaluation, according to the physician, the Veteran was psychiatrically cleared for administrative action. In an April 2007 Reserve Duty Health Assessment, the Veteran indicated that she had not sought counseling or care for mental health during the prior year. Review of the Veteran's treatment records, progress notes, and assessments from the Richmond, Virginia Veterans Affairs Medical Center (VAMC) from 2010 to 2015 reveal that she complained of depression in January 2010. At this time, an examiner opined that the Veteran reported that she tested positive for marijuana at her place of employment and came to the VAMC to enter a substance abuse program. She was hospitalized in November 2011 for polysubstance abuse, during which she enrolled in an in-patient substance-abuse program. She indicated at the time that she was depressed and had had suicidal ideations. There are multiple, sometimes contradictory notations as to mental health concerns in these records. For example, many care providers noted that the Veteran was prescribed medication at bedtime for "sleep and PTSD symptoms." Several clinicians opined that the Veteran self-reported PTSD, major depressive disorder (MDD), attention deficit hyperactivity disorder (ADHD), panic anxiety, skin picking, and nail picking. One VA psychiatrist provided an assessment of substance-induced mood disorder (SIMD), PTSD, polysubstance dependence as well as a history of ADHD, indicating a Global Assessment of Functioning (GAF) score of 60-indicative of moderate symptoms of mental illness. This examiner did not mention whether these assessments were related to active service. Likewise, another VA psychiatrist provided an impression of cocaine dependence in remission, alcohol abuse, and PTSD by history. Again, active service was not mentioned. However, during the course of VA treatment, examiners and clinicians noted that she has had a long history of drug and alcohol abuse and OCD. In a March 2015 Women's Health Note, a clinician reported that the Veteran's PTSD screening test results were negative. Her cumulative score was zero. In an April 2015 email the Veteran wrote that she witnessed an incident in Kuwait in which a soldier had his head crushed in a forklift accident. In May 2016, the Veteran submitted a statement, via VA FORM 21-4138. She reiterated the forklift incident. Also, she stated that children aimed assault weapons at the transport vehicle she drove while she was in active service in Kuwait. In her own words, "she could not get these images out of her head." In a list at the end of her statement, the Veteran noted that her present issues of skin picking and nail and toenail biting began is service. In May 2016, the Veteran was afforded a VA examination by a VA psychologist. The examiner reviewed the claims file, evaluated the Veteran's medical treatment history, considered the Veteran's lay accounts, and conducted an in person examination. The examiner opined that the Veteran did not have a diagnosis of PTSD that conforms to DSM-5 criteria; however, she opined that the Veteran did have a diagnosis of anxiety disorder, unspecified and ADHD. In her examination report, the psychologist noted that the Veteran reported "terrible and volatile" family relationships, physical abuse by her parents, and a history of alcohol abuse and illegal substance abuse. As to etiology, the psychologist reported that the Veteran's claimed PTSD was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As a rationale for this opinion, she noted that a thorough review of the Veteran's medical records and information obtained during the VA examination indicated that the Veteran did not meet the diagnostic criteria for PTSD as laid out in the DSM-5. In January 2017, a staff psychiatrist from the Richmond VAMC submitted a letter. He noted that he first treated the Veteran in June 2015 and most recently in September 2016. Telephone contacts also occurred. The Veteran's primary symptoms at the times of treatment were: anxiety with panic attacks; poor sleep; some depressive symptoms; and problems focusing and concentrating. The Veteran reported that she had been diagnosed in the past with ADHD. Moreover, this psychiatrist wrote that the Veteran alluded to some traumatic experiences during service and stated that she had been diagnosed with PTSD. The psychiatrist concluded by stating that it was agreed that it would be prudent for the Veteran to return to the PTSD program for more evaluation and treatment. Therefore, he wrote a referral. The psychiatrist's letter was silent as to the Veteran's complaint of trichotillomania. In her January 2017 Notice of Disagreement (NOD), the Veteran stated that she did not have PTSD prior to entering active service She also stated that her trichotillomania is related to her PTSD condition. The same month, the Veteran submitted a statement, via VA FIRM 21-4138. As to her PTSD claim, she reported that the "logistics" of substantiating that she did not have PTSD prior to service was affecting her sanity and causing extreme grief. As to trichotillomania, she wrote that skin picking is an extremely crucial side of her PTSD. In January 2017, a VAMC dermatology clinic physician assistant (PA) submitted a letter. She wrote that the Veteran had been followed by the Clinic. She reported that the Veteran requested the Clinic's opinion on her trichotillomania in connection with her PTSD. Citing a military medicine journal, she noted that investigators found that trichotillomania patients had a higher prevalence of PTSD than the general public, positing that trichotillomania symptoms may serve as a coping mechanism to manage PTSD symptoms, possibly through distraction. This PA noted that the Clinic's opinion is congruent with the journal. The PA's letter provides no medical findings or treatment protocols specific to the Veteran. Moreover, the PA did not indicate whether the Veteran had received formal impressions of either PTSD or trichotillomania. In her June 2017 Substantive Appeal (VA FORM 9), the Veteran stated that she was diagnosed with PTSD in November 2011 and has been treated for the disorder at the Richmond VAMC. Moreover, the Veteran stated that she was diagnosed with trichotillomania in January 2011, underscoring that the VA dermatology clinic PA provided a letter, bolstered by findings in military medical literature, linking the coincidence of her diagnosis of trichotillomania and PTSD. A June 2017 letter from a psychiatrist at the VAMC reported that the Veteran had been seen by her a total of three times. The last occasion occurred in July 2012. The psychiatrist wrote that her assessment of the Veteran in July 2012 was: SIMD; polysubstance dependence (cocaine, alcohol and cannabis); PTSD; and a history of ADHD. She also reported that the Veteran's PTSD was due to childhood physical abuse. In December 2017, the Veteran's representative submitted a statement (dated October 2017). She contended that the May 2016 VA psychologist failed to address whether the Veteran's diagnosed anxiety disorder, unspecified was related to military service. As noted above, the Board has framed an acquired psychiatric disorder, to include PTSD in light of alternative psychiatric disorders raised by the evidence of record. Clemons, supra. The Veteran's representation has also advanced the proposition that the Veteran is entitled to service connection for an acquired disorder, to include OCD with symptoms of trichotillomania (hair puling disorder) and excoriation (skin picking). As noted above, the Veteran's STRs do not provide an impression of OCD; without an in-service incurrence, service connection cannot be established. See Holton, supra. Furthermore, the Board notes here that under the broadened scope of Clemons, entitlement to service connection for an acquired psychiatric disorder would include OCD had The Board recognizes that post-service treatment reports from the Richmond VAMC provided impressions of PTSD, depression, SIMD, and polysubstance abuse disorder. Nevertheless, the VAMC reports do not establish a basis for the conclusions that were reached; and, moreover, these reports do not mention whether any of these assessments were related to the Veteran's active service. Rather, as but one example, a VAMC psychiatrist provided an impression of SIMD; polysubstance dependence (cocaine, alcohol and cannabis); a history of ADHD; and PTSD, reporting that the Veteran's PTSD was due to childhood physical abuse. The Board also notes that multiple notations in the Veteran's VAMC records include self-reported symptoms, without specific findings, as to an acquired psychiatric disorder to include PTSD and service. To the extent that there is a history of preservice abuse, such "stressor" does not establish that PTSD predated service or that she had PTSD during service. The presumption of soundness is not raised in such situation. The probative value of the VAMC reports and the Veteran's lay assertions are outweighed by the weight of evidence that reflects that the Veteran does not meet the diagnostic criteria for PTSD. The March 2015 VA Women's Health clinician reported that the Veteran's PTSD screening test results were negative with a score of zero. Furthermore, the May 2016 VA psychologist specifically found that the Veteran's symptoms do not meet the diagnostic criteria for PTSD. While this psychologist opined that the Veteran did have a diagnosis of anxiety disorder, unspecified and ADHD, she also opined that the Veteran, by her own account, had "terrible and volatile" family relationships, physical abuse by her parents, and a history of alcohol abuse and illegal substance abuse. As to an acquired psychiatric disorder, this psychologist noted that the Veteran's mental status examination revealed that the Veteran was alert, responsive, and showed no evidence of distractibility. Moreover, her mood and affect were within normal limits, and her memory functions were grossly intact. Through an extensive review of the Veteran's claims file and examination findings, the psychologist drew no lines of continuity between the Veteran's post service diagnosis of anxiety disorder, unspecified and the Veteran's active service. The psychologist noted that the Veteran stated that she received individual therapy for 6 weeks while in service, and received a prescription for antidepressants-both of which are not reflected in her STRs. Her report of extensive treatment (6 weeks) during service are inconsistent with the record and not credible The VA psychologist's opinion is entitled to substantial probative weight. In light of the paucity of evidence in the STRs and absence of fully substantiated impressions with rationales in the VAMC records; this psychologist's reasoned conclusions are consistent with the evidence of record. The Board finds the psychologist's May 2016 opinion to be both reliable and adequate; it was provided after thorough review of the claims file, consideration of lay statements, an examination of the Veteran, accurate findings, and a rationale for the opinion; there is no credible evidence of PTSD. When PTSD was mentioned, it was noted as history or a notation unsupported by examination or findings. As to other diagnoses, the record reflects notations of anxiety and OCD. However, as with any acquired pathology, there is no probative evidence linking the diagnosis to service and there were no in-service manifestations. We will repeat that prior to discharge based upon conduct, an evaluation was conducted and there was no psychopathology. Her, report that she had in-service manifestations of a psychiatric disability is inconsistent with this report in conjunction with separation and is not credible. As to the Veteran's claim of trichotillomania, the Veteran did not assert that it was related to her military service until January 2017, when she submitted her NOD. See Pond v. West, 12 Vet. App. 341 (1999) (although the Board must take into consideration the veteran's statements, it may consider whether self-interest may be a factor in making such statements). The evidence of record does not provide an impression of trichotillomania. Here, the Board notes that the VA dermatology clinic PA provided neither medical findings, indication of claims file review, nor reference to courses of treatment in her January 2017 letter. As the evidence of record fails to substantiate a current disability of trichotillomania, service connection on a secondary basis cannot be established as a matter of law. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In assessing these claims, the Board has considered the Veteran's lay assertions. She is competent to report what is heard, felt, seen, or smelled. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, her statements are of far less probative value and less credible than the evaluations and observations prepared by skilled professionals. The appellant does not have PTSD and any other disorder was not manifest during service and is not attributable to service. The preponderance of the evidence is against the Veteran's claims and there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. at 49. ORDER Service connection for an acquired psychiatric disorder to include PTSD is denied. Service connection for trichotillomania is denied. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs