Citation Nr: 18148111 Decision Date: 11/07/18 Archive Date: 11/06/18 DOCKET NO. 10-21 940 DATE: November 7, 2018 ORDER Service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied.   FINDING OF FACT The Veteran does not have PTSD, depressive disorder or bipolar disorder; and the Veteran’s alcohol use disorder is not service connectable. CONCLUSION OF LAW The criteria for service connection for a psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 105, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.301, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1982 to January 1994. The case is on appeal from a July 2008 rating decision. The Veteran had a Board hearing in May 2013. The claim most recently came before the Board in May 2018 and was remanded for further development. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).   Service connection for a psychiatric disorder, to include PTSD. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “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. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Where drug and alcohol use is at issue, service connection is precluded in two situations: (1) for primary alcohol abuse disabilities; and (2) for secondary disabilities (such as cirrhosis of the liver) that result from primary alcohol abuse. Service connection is not precluded if substance abuse is secondary to a service-connected disability. Even if a veteran has a service-connected disability, however, service connection would be precluded for the alcohol or drug abuse disability if it is due to willful action rather than the result of the service-connected disability. See 38 U.S.C. § 105; 38 C.F.R. §§ 3.1(n), 3.301(c). See also Allen v. Principi, 237 F.3d 1368, 1376, 1378 (Fed. Cir. 2001). Analysis The Veteran contends that she developed PTSD as a result of multiple personal assaults in service. She asserts that she was raped in two separate incidents during service. During the May 2013 Board hearing, the Veteran testified that the first incident occurred during her first duty station. She stated two female staff sergeants raped her at an off-base apartment. She indicated that she reported the incident to her First Sergeants and was switched to a different platoon. She contends the second in-service incident was when she was stationed at her second duty station. She testified a male officer offered her a ride to the motor pool, but instead took a detour to the woods where he raped her. She indicated subsequent to the incident, she reported the assault to her roommate. The Veteran’s service treatment records (STRs) do not contain mental health complaints, treatment or diagnosis. However, a December 1989 service record indicated the Veteran requested reassignment of her military occupational specialty (MOS). Further, an October 1993 record showed the Veteran complained of fatigue, life circumstance stressors for one month and difficulty sleeping. An August 2007 VA treatment record indicated diagnoses of ETOH induced mood disorder, insomnia and depressive disorder. It noted the Veteran was admitted for crisis stabilization and alcohol detox, as she reported an attempted suicide by motor vehicle accident. The examiner reported she was diagnosed with PTSD and referred to the PTSD program. An April 2008 VA treatment record indicated a history of mood disorder, alcohol dependence and reports of continual depression. The examiner reported diagnoses of PTSD and borderline personality disorder. A February 2011 VA record indicated moderate major depressive disorder. Similarly, ongoing VA treatment records, including from May, August and October 2013 noted diagnoses of PTSD, adjustment disorder with depressed mood and bipolar disorder. See also August 2018 VA treatment record. In December 2013, the Board remanded the claim for further development. The Veteran was unable to attend several scheduled VA examinations, although she submitted a March 2015 statement which indicated she was in an alcohol/PTSD treatment facility and was unable to attend. An October 2016 VA opinion was submitted in which the examiner reported diagnoses of PTSD and bipolar disease. He stated the Veteran has a long history of PTSD and bipolar disease; however, no further rationale or explanation was provided for the diagnoses. The Board remanded the claim in December 2016 and the Veteran was afforded an April 2017 VA examination. After review of the record, and based on DSM-5 criteria, the examiner indicated he cannot resolve the question of PTSD within a reasonable degree of confidence as to the nature of her mental disorder without resorting to mere speculation. She stated although the Veteran has received treatment associated with diagnoses of PTSD, bipolar disorder and depression, “the receipt of treatment is not a diagnostic criterion, nor is there evidence in the published empirical literature that a diagnosis of PTSD is at least as likely as not to be valid because one receives treatment associated with it.” The examiner indicated she has an extensive and chronic alcohol use history that has impacted her employment history and also, convoluted the clinical picture. She stated it is impossible to discern without resorting to mere speculation whether the Veteran’s current mood symptoms are related to service or to her extensive alcohol dependency and the resulting psychosocial stressors. She reported the Veteran meets the diagnostic criteria for severe alcohol use disorder and it is less likely than not due to her military service, as she has a history of alcohol abuse prior to service. The Board again remanded the claim in May 2018 for a VA examination to assess the etiology of any diagnosed psychiatric disorder. The Veteran was afforded an August 2018 VA examination in which the examiner concluded the objective evidence supports only alcohol use disorder could be diagnosed for the Veteran. Moreover, he stated, there is overwhelming objective data corroborating her alcohol use disorder, including inpatient admissions which utilized drug screens. He noted the ongoing VA psychiatric treatment the Veteran receives which shows recent diagnoses of PTSD, bipolar disorder, substance induced mood disorder and substance use disorder ETOH. However, he stated, there is no evidence of objective screening used by treatment providers in order to arrive at an accurate diagnosis, and this is not uncommon in the treatment setting. He further reported treating providers can rely solely on patient self-report of symptoms in arriving at their diagnosis and their treatment recommendations. As such, a diagnosis by treating providers does not always provide an indication that the patient is actually experiencing said disorder. The examiner noted in the absence of objective screening for validity, there is no way to ascertain this. Additionally, the August 2018 examiner discussed diagnoses “by history.” He noted that “by history” is not an authorized DSM-IV or DSM-5 specifier but is often used by treating providers to indicate diagnoses that are not in the record or per patient report, and have not been fully assessed by the clinician. He stated the Veteran’s reported symptoms were, at times, inconsistent in the medical record and she was administered a screening tool to assess for invalid/over-reporting of symptoms. He indicated it is statistically likely the Veteran misrepresented her symptoms and such reports are not consistent with known psychopathology. Therefore, he concluded, he concurs with the prior VA examiner in that the only diagnosis able to be rendered based on objective verifiable evidence is alcohol use disorder, and there is no other established mental health disorder. The Board finds service connection is not warranted for a psychiatric disorder, to include PTSD. The most persuasive evidence of record supports that the only psychiatric diagnosis verifiable with objective evidence, and under DSM criteria, is alcohol use disorder. In regard to the Veteran’s diagnosed alcohol use disorder, VA compensation may not be paid for primary substance abuse disabilities, or for secondary disabilities arising from primary abuse. See 38 U.S.C. § 105; 38 C.F.R. §§ 3.1, 3.301. Compensation may only be paid for substance abuse that is secondary to, or a symptom of, a service-connected disability. In this case, while the Veteran has a diagnosis of alcohol use disorder, the evidence of record does not show and the Veteran does not contend that her alcohol use disorder was caused or aggravated by another service-connected condition. See 38 C.F.R. § 3.310; see also Allen at 1381. Because this is not shown to be a condition other than primary, it is not service connectable. The Board acknowledges the indication of diagnoses of other psychiatric disorders in the VA treatment records, including PTSD, depressive disorder and bipolar disorder. However, the Board finds the most probative evidence of record supports a psychiatric diagnosis, other than alcohol use disorder, has not been established based on DSM criteria. The Board find the August 2018 VA examiner’s opinion constitutes the most persuasive evidence of record and of the greatest probative value. It is apparent in the opinion that the entire claims file was reviewed and considered by the examiner, including the prior VA examinations and VA treatment records. His opinion was based on an accurate history with supportive rationale and contains well-reasoned explanations and conclusions. As such, this opinion is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). While psychiatric diagnoses are indicated in the VA treatment records, including PTSD and depressive disorder, these are not supported by adequate rationale. However, the August 2018 medical opinion contains thorough discussion of the record and the Veteran’s symptoms and thus, is afforded more probative weight than the VA treatment records. The examiner explained that diagnoses listed in treatment records are not always representative of a person actually experiencing the disorder. The Board acknowledges the Veteran’s contentions and sympathizes with her psychiatric symptoms. Further, she is competent to testify as to her observations; however, establishing a psychiatric diagnosis which meets DSM criteria is a complex medical question which falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). See also Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (“PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify.”). Therefore, the Veteran’s lay opinion as to her current psychiatric diagnoses is afforded no probative evidentiary value. (Continued on the next page)   Accordingly, the preponderance of the evidence is against the claim of service connection for a psychiatric disorder. The current disability element of the claim is not established, other than for a primary alcohol use disorder, which is not service connectable. 38 C.F.C. §§ 3.1, 3.301. Therefore, the benefit-of-the-doubt doctrine is not applicable and service connection for a psychiatric disorder, including PTSD, is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Isaacs, Associate Counsel