Citation Nr: 18147096 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 14-21 104 DATE: November 5, 2018 ORDER Entitlement to service connection for an acquired psychiatric disability other than posttraumatic stress disorder (PTSD), to include depression and dysthymia, to include as secondary to service connected hearing loss is denied. FINDING OF FACT The weight of the evidence is against a finding that the Veteran’s psychiatric disabilities are proximately due to or have been aggravated beyond their natural progression by his service-connected hearing loss, and there is otherwise no showing that a psychiatric disability is related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The record has raised the possibility that the Veteran’s psychiatric disabilities are secondary to his service connected hearing loss. The Board notes that it denied service connection for PTSD in its October 2017 decision. Consequently, the focus of this decision is psychiatric disabilities other than PTSD. The question for the Board is whether the Veteran has a current disability that is proximately due to, or was aggravated beyond its natural progress by his service connected hearing loss. The Board concludes that, while the Veteran has current diagnoses of senile dementia with depression, dysthymia, and generalized anxiety disorder, the preponderance of the evidence is against finding that the psychiatric disabilities are proximately due to or the result of, or aggravated beyond its natural progression by his service connected hearing loss. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The post service treatment reports reflect diagnoses of senile dementia with depression, dysthymia, and generalized anxiety disorder. A May 2012 treatment report reflects that the Veteran’s “hearing deficit continues to be his primary issues and it affects his depression and socialization.” Pursuant to the Board’s October 2017 remand, the claims file was sent to an appropriate medical clinician, who rendered an opinion in November 2017. He opined that it was less likely than not that the Veteran’s psychiatric disabilities were caused or aggravated by his service connected hearing loss. He noted that hearing loss does have at least a theoretical possibility of worsening certain types of mental disorders beyond their expected progression. For example, a paranoid disorder can be caused or worsened by a progressive, and unacknowledged, hearing loss, causing the patient to believe that others are whispering in his presence for nefarious reasons. The examiner noted that this Veteran does not have a paranoid disorder, and is aware of his hearing loss. The examiner noted that a hearing disorder that the patient tries to hide from others may be mistaken for a memory impairment, when in fact the problem is not that the patient has forgotten what he heard, but that he never understood it in the first place. The examiner pointed out that this Veteran’s dementia has an identifiable cause, responds to treatment, and does not occur in the context of attempts to hide his hearing impairment, so this hypothesis is not supported. The examiner noted that an anxiety disorder could presumably be worsened by a hearing loss, especially if the disorder includes a strong fear of negative social evaluation by others, and/or if there is a strong obsessional component such that reduced moment-to-moment awareness of one’s environment due to hearing loss aggravates the anxiety. The same case could be made more strongly for PTSD, as patients have a strong need to be aware of their surroundings. However, the examiner found that recent treatment notes do not support the theoretical possibility of this Veteran’s anxiety disorder being worsened by his hearing loss. The examiner noted that depression can be worsened by hearing loss, as it interferes with social interactions and activities that give joy and meaning to life. A single note from 2012 makes a clear connection between this Veteran’s hearing loss and his depression. However, the examiner noted that more recent notes do not support a nexus between this Veteran’s hearing loss and his depression. Furthermore, they indicate current effective communication between this Veteran and his providers. The examiner found this to be strong evidence that his hearing loss is not so severe as to isolate this Veteran from the give-and-take of social interaction. Finally, the examiner noted that recent notes imply that his dementia is a more likely cause of this Veteran’s depression, and in any case depression appeared to be under fairly good control at the moment. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional’s opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician’s special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. There are substantial and significant factors which favor the valuation of the November 2017 VA medical opinion over the opinion expressed in the May 2012 treatment report. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Board finds that both opinions equally satisfy the first two factors. The November 2017 examiner was familiar with the Veteran’s medical history in that he reviewed the claims file and cited to it. The May 2012 examiner appeared to be rendering treatment; and the Board presumes that the Veteran made the examiner aware of his medical history. With regards to the second factor, both examiners rendered an unequivocal opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). It is this factor in which the November 2017 VA examiner’s opinion is superior. The November 2017 VA examiner recognized the theoretical possibility that a hearing loss disability could cause or aggravate a psychiatric disability. However, he then noted several of the typical ways in which such causation or aggravation would occur. He then cited to the claims file (even to the May 2012 treatment report) to distinguish this Veteran’s case from others in which such causation or aggravation would be likely. He specifically noted that while the May 2012 examiner made a clear connection between this Veteran’s hearing loss and his depression, more recent notes do not support such a nexus. For the foregoing reasons, the Board finds the November 2017 VA examiner’s opinion to be more probative than the March 2012 treatment report. While the Veteran believes his psychiatric disabilities are proximately due to or the result of/aggravated beyond its natural progression by service-connected hearing loss, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the November 2017 VA examiner’s opinion. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s psychiatric disabilities are related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). However, in this case, the service treatment records fail to reflect any findings attributed to a psychiatric disability. To the contrary, the Veteran underwent an August 1957 separation examination and completed an August 1957 Report of Medical History. The examination yielded normal findings. In the Report of Medical History, the Veteran specifically denied depression or excessive worry; frequent or terrifying nightmares; or nervous trouble of any sort. Finally, the Veteran has not contended that his psychiatric disability has been continuous since service; and there is no evidence that it has been. (Continued on the next page)   While the Veteran may believe his psychiatric disabilities are directly related to service, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Prem, Counsel