Citation Nr: 18146515 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-23 541 DATE: October 31, 2018 ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for other acquired psychiatric disorders, to include anxiety disorder and depression is remanded. FINDING OF FACT The preponderance of the evidence is against finding that there is a current diagnosis of post-traumatic stress disorder (PTSD) that began during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW 1. The criteria for entitlement to service connection for post-traumatic stress disorder have not been met. 38 U.S.C. §§ 1113, 5107(b) (2012); 38 C.F.R. §§ 3.303, 3.304(f) (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Navy from January 1980 to March 1980. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from Department of Veteran Affairs (VA) Regional Office rating decision in January 2013. The Veteran has perfected the appeal. See February 2014 Notice of Disagreement; March 2016 Statement of the Case; May 2016 Form-9. Service Connection A Veteran is granted service connection where the evidence shows that an injury or disease that results in a current disability was incurred during service or was aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. §3.303(a). To be entitled to service connection, the evidence must support (1) a current disability; (2) an in-service injury or event; and (3) a nexus between the current disability and the in-service injury or event. 38 C.F.R. §3.303(a). To establish service connection for PTSD, a Veteran must satisfy three evidentiary requirements. First, there must be medical evidence diagnosis the condition in accordance with 38 C.F.R. § 4.145(a) (i.e., the criteria in the Diagnostic and Statistical Manual for Mental Disorders (DSM)). Second, there must be a link, established by medical evidence, between the current PTSD symptoms and an in-service stressor. Third, there must be credible supporting evidence that claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). When there is an approximate balance of positive and negative evidence regarding any material issues, the Secretary shall give the benefit of the doubt to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for post-traumatic stress disorder (PTSD) Veteran contends that he currently has PTSD due to an in-service stressor he experienced while in boot camp. In his NOD, received in February 2014, he maintains that he suffered a psychotic episode while in boot camp. He further contends that he could not take the pressure from boot camp. The Veteran relates that he had a psychological examination during boot camp and was diagnosed with being a hypochondriac. He believes that the incident in boot camp was the spark that started him down the path of mental illness, relating that he can barely control the voices, disorientations, hallucinations, and the abnormal behavior. In a statement, received by VA in January 2013, the Veteran describes an incident while stationed at a Naval Base in Great Lakes, in which a drill instructor read a personal letter to a friend in front of people. He recounted that as a result of this incident, he was very upset and never wrote another letter. Also, the Veteran related that there were other incidents where he got into arguments with his commanding official. The Veteran also claims in the statement in support of claim for PTSD, received by VA in November 2012, that in April 1980, he suffered a nervous breakdown after he left his job and suffered severe hallucinations. The Veteran’s December 1979 entrance examination does not note any previous history with psychiatric complaints. In February 1980, the service records reflect the Veteran’s complaints of insomnia. In addition, it was noted that the Veteran was given a psycho-diagnostic test after an evaluation regarding his knee pain; the evaluation of the knee concluded that there was no medical cause for his claimed knee pain. It was stated that the testing was indicative of hysterical features. A mental status examination was conducted and the Veteran’s status was within normal limits. Further noted is that there was no evidence of psychosis, neurosis, or organic brain syndrome. It was concluded that the Veteran’s “apprehensiveness, liability, exaggerated dramatics, suggestibility, and problems with histrionic behavior are so severe as to make it unlikely that he can adapt successfully to training or the service.” There was no notation of a PTSD diagnosis. In the Veteran’s certificate of release or discharge from active duty, it was noted as the reason for separation, “burden to command due to substandard performance”. In the Veteran’s private medical records from 1982 to 1984, it was noted that the Veteran had symptoms of mental illness and is likely to cause injury to himself and others. He was also diagnosed with schizophrenia, paranoid type. There was no diagnosis of PTSD. In private medical records that detailed the Veteran’s hospitalization from 1981 to 2007, it was noted that Veteran had not been himself since his mother’s death in 1980. It was also noted that the Veteran experienced hallucinations and threatened his father. In these records, the Veteran was diagnosed with atypical psychosis, histrionic personality traits, and schizophrenia. There was no diagnosis of PTSD. In the VA treatment records, the Veteran was tested twice for depression and PTSD in September and December 2012. He scored negative for both depression and PTSD both times. He was again diagnosed with schizophrenia. Also noted is that his father was once diagnosed with PTSD. There is a notation under past medical history that reads “PTSD v. Schizophrenia”. However, there is still no diagnosis of PTSD for the Veteran. The Social Security Administration (SSA) records show a diagnosis for schizophrenia and drug-induced psychosis. There is no diagnosis of PTSD. After a careful and considered review of the evidence of record, including the Veteran’s contentions, the Board finds that there is no medical evidence on the record that supports a current diagnosis of PTSD. As aptly noted by the record, the Veteran was tested twice for PTSD, and the results were both negative. The Veteran has had multiple hospital visits regarding his mental health. In those visits, he was diagnosed with other psychiatric disorders; none were PTSD. Specifically, the medical professionals in service were in the best position to contemporaneously assess the Veteran and consider his complaints and determine that his symptoms were not indicative of a mental condition. In addition, the post-service treating medical professionals, including the testing and hospital treatment pertaining to his mental health, provide significant probative weight to the Board’s finding that the Veteran has no current PTSD diagnosis. Based on the evidence on the record, the Board finds that the most competent and probative evidence is against a finding of service connection for PTSD. The Board does consider the Veteran’s statements regarding his claimed diagnosis of PTSD. However, the Board does not give any probative weight based on the evidence on the record. The Veteran has not demonstrated he possesses the knowledge and medical expertise needed to competently assess his own psychiatric diagnosis. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran has not demonstrated the medical expertise required for this matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). Regarding the Veteran’s claim of an in-service stressor, regardless of whether an in-service stressor occurred, without evidence to show that the Veteran currently suffers from PTSD, service connection cannot be granted. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board finds that the weight of the evidence is against a finding of service connection for PTSD. The Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, the doctrine is not applicable. REASONS FOR REMAND 1. Entitlement to service connection for other acquired psychiatric disorders, to include anxiety disorder and depression is remanded. After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the Veteran’s claim of entitlement to other acquired psychiatric disorders, to include anxiety disorder and depression as claimed by the Veteran. The Veteran contends that he suffers from anxiety and depression based on the psychotic episode he experienced while in boot camp. He further contends that he could not take the pressure of boot camp, and that since discharge, he has been diagnosed with more mental health disorders, including depression, schizophrenia, and bi-polar disorder. The Veteran’s December 1979 entrance examination does not note any previous history with psychiatric complaints. In February 1980, the service records note the Veteran’s complaints about insomnia. In addition, it was reported that the Veteran was given a psycho-diagnostic test after an evaluation regarding his knee pain concluded that there was no medical cause for his knee pain. It was stated that the testing was indicative of hysterical features. Following mental status examination, the Veteran’s status assessed as within normal limits. There was no evidence of psychosis, neurosis, or organic brain syndrome. It was concluded that the Veteran’s “apprehensiveness, liability, exaggerated dramatics, suggestibility, and problems with histrionic behavior are so severe as to make it unlikely that he can adapt successfully to training or the service.” In the Veteran’s certificate of release or discharge from active duty, it was noted as the reason for separation, “burden to command due to substandard performance”. In the private medical records from 1982 to 2007, there are diagnoses for schizophrenia, atypical psychosis, and histrionic personality traits. Diagnosis for anxiety disorder or depression are absent in the records, although it was noted that he was previously hospitalized for depression. There is also a notation that the Veteran had not been himself since his mother’s death in July 1980. The Social Security Administration (SSA) records show a diagnosis for schizophrenia and drug-induced psychosis. In a record dated July 1982, it is noted that the clinical impression of the Veteran’s diagnosis is atypical psychosis and depression. The Veteran claims that he receives benefits for partially differentiated schizophrenia. In the VA treatment records from 2012, the Veteran was tested for depression and PTSD. He scored negative for both depression and PTSD in September and December 2012. He was again diagnosed with schizophrenia. The records also show that the Veteran is receiving medication for treatment. The Veteran has not been afforded a VA examination for these conditions. The Board is of opinion that an examination for a medical opinion is necessary according to McClendon v. Nicholson, 20 Vet. App. 29 (2006). The Veteran has been denied service connection thus far because there was no evidence showing a chronic disability in service or that his current disability is related to military service. Based on the evidence of the record, there is evidence that the Veteran has a current diagnosis of an acquired psychiatric disorder, diagnosed as schizophrenia, psychoses, etc. Also, there is evidence establishing that an in-service injury or event occurred. The Veteran’s service records show that the Veteran was given psychodiagnostic testing and a mental health status exam during his service. It was stated that the Veteran was exhibiting “hysterical features” and “exaggerated dramatics”. There was also a complaint with insomnia during his service. There is an indication that his current mental diagnoses can be related to what occurred during his brief active service. The Veteran was not recommended for reenlistment as a result of the evaluation and was ultimately discharged has showed continuous symptoms of mental illness since his separation from service, detailed by his many hospitalizations in the private medical records. The Board finds that a VA examination is necessary to determine the nature and etiology of the Veteran’s current diagnosis and whether his current disability is related to his service. The matter is REMANDED for the following action: 1. Provide the Veteran an opportunity to identify any pertinent treatment records for his claimed disabilities. The RO/AMC should secure any necessary authorizations. 2. Additionally, all updated VA treatment records should be obtained. If any requested outstanding records cannot be obtained, the Veteran should be notified of such. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his currently diagnosed psychiatric disorders. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The claims file should be made available to the examiner for review. After record review and examination, the VA examiner should offer his or her opinion with supporting rationale as to the following inquiries: (a) Does the Veteran have a current diagnosis of any acquired psychiatric disorders, to include anxiety disorder, depression, schizophrenia, etc. (b) If the answer to (a) is yes, is it at least as likely as not (50 percent or greater probability) that the Veteran's acquired psychiatric disorders were incurred in, caused by, or etiologically related to the Veteran's service? The basis for each opinion is to be fully explained with a complete discussion of the pertinent lay and medical evidence of record and sound medical principles, including the use of any medical literature or studies, which may reasonably explain the medical analysis in the study of this case. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Syesa Middleton, Associate Counsel