Citation Nr: 18148256 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 12-24 357 DATE: November 7, 2018 ORDER Service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) is denied. Service connection for coronary artery disease, to include as secondary to PTSD, is denied. FINDINGS OF FACT 1. The preponderance of the evidence indicates that the Veteran does not have PTSD. 2. The preponderance of the evidence indicates that the Veteran’s psychiatric disability did not have its onset in active service and is not otherwise related to service. 3. The preponderance of the evidence indicates that the Veteran’s coronary artery disease did not have its onset in active service, is not related to a service-connected disability, and is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have not been met. 38 C.F.R. §§ 1131, 5103, 5103a, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2017). 2. The criteria for service connection for coronary artery disease have not been met. 38 C.F.R. §§ 1131, 5103, 5103a, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1979 to November 1983. In May 2014, the Veteran testified at a videoconference hearing before a Veterans Law Judge (VLJ) who is no longer at the Board. He was provided an opportunity to request another hearing, but in October 2017 and February 2018 he indicated he did not wish to appear at another Board hearing. These matters were previously before the Board in January 2015 and May 2018, at which times they were remanded for further evidentiary development. Service Connection To establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Acquired Psychiatric Disorder The Veteran’s current treatment records reflect various psychiatric diagnoses. These have included depressive disorder, polysubstance (alcohol/cannabis) abuse disorder, intermittent explosive disorder (IED), schizotypal personality disorder, and PTSD. In addition to the general service connection requirements for psychiatric disorders, service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between the current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). The Veteran has contended that he has PTSD which stems from an incident which occurred while serving in Panama in 1982. He was drinking at a non-commissioned officers’ club on base and stepped outside to smoke a cigarette when someone came up behind him and hit him on the back/crown of his head with a beer bottle. He fell down and reportedly lost consciousness and woke up to find the back of his head bloody and people standing around looking at him. The Veteran’s service treatment records (STRs) do not contain complaints, symptoms, treatment, or diagnosis of a psychiatric condition. Normal psychiatric findings were listed on the May 1978 enlistment examination report. The STRs do however document the claimed stressor incident, noting that he was hit in the head with a bottle in February 1982, resulting in a cerebral concussion and sutures to the back of his head. The Board notes that the Veteran is separately service-connected for a traumatic brain injury (TBI) in connection with that incident. In an October 1983 report of medical history, the Veteran reported that he did not have current or past trouble sleeping, depression or excessive worry, or nervous trouble of any sort. An October 1983 mental status evaluation indicated that the Veteran had normal behavior, was fully alert, had level mood, had clear thinking process, had normal thought content, and his memory was fair. The report further found that the Veteran did not have significant mental illness; was mentally responsible, able to distinguish right from wrong, and able to adhere to the right; had the mental capacity to understand and participate in board proceedings, and met the retention standards prescribed. Several military personnel records and statements have indicated that the Veteran had some instances of disorderly behavior and misconduct. Post-service, VA treatment records documented that when the Veteran sought VA treatment for his coronary artery disease, he was administered PTSD and depression screens which were positive. He was referred for mental health treatment in November 2009. Initial intake screens identified problems of a history of substance abuse (alcohol and marijuana), grief related to the death of loved ones, and depression. He became a regular outpatient and was prescribed various medications to treat problems sleeping and depression symptoms. He reported to clinicians that he used drugs continuously from 1978 to 2009, specifically marijuana and cocaine, and that he drank alcohol excessively during that time and continued to drink. In February 2010, a psychiatrist who would become his regular VA clinician conducted a mental status examination and gave initial diagnoses of addictive disorder (alcohol abuse, cannabis, abuse, tobacco use), IED, and personality disorder/traits not otherwise specified (NOS). At a follow-up appointment in June 2010 in which another mental status examination was performed, the VA psychiatrist diagnosed polysubstance abuse in early partial remission, and possible IED versus undiagnosed PTSD. In association with a claim for Social Security Administration (SSA) disability benefits, the Veteran underwent a psychiatric evaluation in September 2010. The psychologist determined that the only diagnoses he could discern from the Veteran’s medical history were alcohol/cannabis abuse with tobacco use, IED, and personality disorder traits NOS. However, he found that it was unclear from his examination whether the Veteran met the criteria for IED. The Board notes that the Veteran was granted SSA disability benefits due primarily to his coronary artery disease and secondarily to an affective/mood disorder. In September 2010, the Veteran reported to his social worker that he had been told he had PTSD. The social worker noted that she educated the Veteran about the diagnosis of PTSD and that based on his history, presentation, and symptom reports, he did not suffer from PTSD. Following another mental status examination in September 2010, his VA psychiatrist diagnosed polysubstance dependence in early partial remission and possible PTSD. In August 2011, after a mental status examination, the VA psychiatrist diagnosed past polysubstance abuse in remission and probable PTSD. After another mental status examination in November 2011, the psychiatrist diagnosed polysubstance abuse in sustained remission and PTSD. Subsequently, PTSD was listed as an ongoing condition in the Veteran’s VA records. Besides brief mental status examinations and PTSD screenings, there were no full PTSD evaluations conducted by the Veteran’s treating clinicians throughout the appeal period. He began group therapy for PTSD symptoms and continued to take medications for depression symptoms and trouble sleeping. In October 2013, the Veteran’s new treating psychologist diagnosed alcohol abuse and major depressive disorder and referred him to join a TBI support group. In March 2014, she diagnosed alcohol use disorder, persistent depressive disorder with anxious distress, and rule-out PTSD. In July 2014, she diagnosed alcohol use disorder, persistent depressive disorder, rule-out schizotypal personality disorder, and neurocognitive disorder due to TBI. She subsequently diagnosed schizotypal personality disorder. In October 2014, it was noted that the Veteran relapsed and had begun using marijuana again. In July 2016, VA clinicians noted that the Veteran had no diagnosis of PTSD. His most recent VA treatment records indicate that he has a diagnosis of mood disorder/depression and continues medication treatment for his depressive symptoms. There are several complete psychiatric evaluations of record. The Veteran underwent a VA psychiatric examination in April 2011. The examiner indicated that he had diagnoses of depressive disorder, NOS; IED, by history; and polysubstance dependence, in early partial remission. The examiner opined that the Veteran did not meet the clinical diagnosis for PTSD based on the evaluation and the information reviewed. Another VA examination conducted in April 2013 found that the Veteran had a diagnosis of depressive disorder and did not have a diagnosis of PTSD. The examiner indicated that the Veteran’s reported stressor of being hit in the head with a beer bottle and briefly losing consciousness was not adequate to support the diagnosis of PTSD (Criteria A) and was not related to the Veteran’s fear of hostile or military terrorist activity. The examiner further determined that there was no evidence that there was a relationship between his mood disorder and his service. A VA psychiatric evaluation was conducted in January 2017 and the examiner determined that the Veteran did not meet the criteria for PTSD and opined that he did not present with a stressor that would typically lead to PTSD and he was not reporting PTSD symptoms. The examiner explained that the stressor would not lead to the current mood disorder, though he did report that he thinks about the incident, and that irritability, sleep problems, and anhedonia began sometime after the assault. He also reported mood symptoms, but there was no evidence in his current presentation or history that his mood symptoms were related to service or his reported stressor. The examiner opined that it was less likely than not that there was a connection between his mood disorder and service. The examiner further indicated that the Veteran was not currently drinking and had abstained for a year, but continued to have mood symptoms consistent with the last examination. The examiner determined that this fact strongly argued against a connection between his mood disorder and his drinking. The examiner further opined that the Veteran did not present with PTSD and therefore there was no connection between his drinking and PTSD. The examiner explained that regarding being asked to reconcile the diagnoses of PTSD, depressive disorder and IED, the Veteran was presenting with a stressor that less likely than not would cause PTSD and he was not reporting PTSD symptoms, which was consistent with his previous examination, and based on that, the examiner did not believe PTSD was an accurate diagnosis. In regard to depressive disorder, the examiner explained that his presentation and history were consistent with a mood disorder. In regard to IED, the examiner determined that he was not reporting symptoms of this other than to state that he was quite irritable. The Veteran stated that after his assault he was in two fights and had two domestic incidents, with the last in 1985. The examiner explained that, based on history, the Veteran’s self-report, and his current presentation, he did not meet criteria for IED. The Veteran underwent another VA psychiatric evaluation in June 2018. The examiner determined that his history and symptoms did not meet the criteria for a diagnosis of PTSD, consistent with the three prior VA examination findings. She did diagnose depressive disorder NOS, alcohol dependence, and cannabis dependence in full, sustained remission. She stated that because of his extensive history of alcohol abuse, an alcohol-induced depressive disorder could not be ruled out. She also determined that he had no symptoms secondary to a history of a TBI that would be relevant to his mental health diagnoses. The examiner stated that the Veteran’s drinking and drug usage began prior to military service, and as such, the presumed etiology of his alcohol dependence and prior drug dependence would be that he chose to use substances. She continued that the difficulties that followed in his life secondary to his polysubstance usage were the likely etiology of his depressive symptoms. The Veteran reported that he got lost while driving, could not use a GPS, and had to call friends and relatives when he was driving because he forgot where he was going. However, the examiner noted that he drove himself to his appointment without difficulty and without anyone accompanying him, and he routinely drove to North Carolina for VA treatment without difficulty. She also reported that the Veteran initially presented with what appeared to be an extremely exaggerated presentation of stammering and stuttering when answering a simple question. The record established that the Veteran had some stuttering prior to his service. However, she noted, when he was describing in detail something that he wanted to talk about, his stammering and stuttering almost disappeared. She determined that the overall appearance was not of genuine dysfluency and that an extreme level of dysfluency was not documented in his records. As such, no symptoms secondary to a history of a TBI were relevant to his mental health diagnoses The examiner found that the Veteran’s reported stressor would be adequate to support a diagnosis of PTSD as related to personal assault. However, it was less likely than not that any psychiatric disorder was incurred in or caused by the in-service stressor, as he did not have a diagnosis of PTSD meeting the criteria of DSM-IV/V. Although he did have current diagnoses of depressive disorder NOS, alcohol use disorder, and cannabis use disorder, there was no evidence that they were related to his military service, noting that his substance abuse began prior to service. Accordingly, she determined that there was no nexus between military service and the current diagnoses. There are several relevant lay statements of record, as well. At the May 2014 hearing, the Veteran stated that he was in ongoing group mental health therapy and took medication for his psychiatric disorders. He stated that he started drinking and using marijuana to self-treat his PTSD symptoms. He also argued that the opinion of his treating physician, who he stated diagnosed him with PTSD in November 2011, was more persuasive than that of the VA examiners who only interviewed him for a short time. Several lay statements from the Veteran’s daughter described observing her father’s sleep disturbance, anger, drinking problem, yelling, waking up with cold sweats, confusion, isolating behavior, frustration, and agitation. The Board finds that the preponderance of the evidence indicates that the Veteran does not have PTSD. Although PTSD has been listed as an ongoing condition in VA treatment records, a diagnosis of PTSD based on a complete evaluation is not of record. PTSD screens based on self-report and brief mental status examinations suggested PTSD, from which the listed condition of PTSD was derived. Formal VA examinations consistently found no symptoms supporting diagnoses of PTSD. The Board finds the examiners’ findings competent and credible, as they are well-reasoned, detailed, and consistent with the other evidence of record including the Veteran’s medical history. As such, the Board attaches significant probative value to the examiners’ findings. With no diagnosis of record based on a full psychiatric evaluation of the Veteran, service connection for PTSD is not supported. There was no evidence in service of a psychiatric condition. Indeed, an evaluation done just prior to separation specifically found that the Veteran did not have a mental health condition. There is no indication that the Veteran suffered from psychiatric complaints until November 2009, many years after service. There are no medical opinions of record which have found that his depressive disorder had its onset in service or is otherwise related to service. Polysubstance abuse began prior to service and has not been found by any clinician of record to be related to the Veteran’s service. Accordingly, service connection for an acquired psychiatric disorder (other than PTSD) has not been established. The Board notes that the Veteran submitted a statement in September 2018 requesting another psychiatric opinion as he did not tell the June 2018 VA examiner that he used cannabis and he did not want that statement used against him. However, there is ample evidence in the claims file that the Veteran reported marijuana use to clinicians and had numerous diagnoses of polysubstance abuse. As such, whether or not the Veteran mentioned his cannabis use to the examiner, it is apparent she reviewed the medical records in the claims file and determined her opinions based upon the Veteran’s lay and medical history, as well as the in-person examination results. Accordingly, the Board finds that the VA opinions of record provide an adequate basis upon which to determine the claim. The Board finds that the preponderance of the evidence is against granting service connection. The benefit of the doubt doctrine is not applicable in this case as there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 57. 2. Coronary Artery Disease The Veteran has contended that his coronary artery disease had its onset in active service or was proximately caused or aggravated by an acquired psychiatric disability, to include PTSD with alcoholism. In addition to direct service connection, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303. The Veteran’s May 1978 service enlistment examination report noted normal findings on clinical evaluation, including normal heart and normal vascular system. A May 1983 consultation sheet indicated that the Veteran had a suspected diagnosis of a heart murmur. He was referred for outpatient care and the clinician believed it was actually an S3 beat heard best at the apex. He was referred for cardiac evaluation, and an electrocardiogram (EKG) was within normal limits. His October 1983 separation report of medical history indicated normal findings upon clinical evaluation, including normal heart and normal vascular system. The Veteran reported that had not had shortness of breath, or pain or pressure in his chest. Post-service, the Veteran was treated by private clinicians and had a discharge diagnosis in October 2008 of coronary artery disease. He experienced a non-ST elevation myocardial infarction and subsequently had three stents inserted. He has undergone cardiac monitoring and treatment since that time. The Veteran underwent a VA examination in April 2013. Diagnoses of acute, subacute, or old myocardial infarction and coronary artery disease were noted. The examiner determined that the Veteran’s current coronary artery disease was less likely than not related to service, explaining that because the May 1983 possible murmur was subsequently determined S3 which is normal in people under 40 years old, his EKG was within normal limits, and his coronary artery disease and myocardial infarction were diagnosed over 25 years after service, the condition was more likely related to lifestyle than to military service. At the May 2014 hearing, the Veteran stated that he had pressure in his chest and shortness of breath in service which he felt were related to his later diagnosis of coronary artery disease. He also testified that his depression from PTSD led to his drinking, which in turn led to his coronary artery disease. Although the Veteran reported at the hearing that he experienced pressure in his chest and shortness of breath in service, he specifically denied such symptoms at separation. The Board finds the April 2013 VA examiner’s determination to be competent and credible, as it is well-reasoned, detailed, and consistent with the other evidence of record including the Veteran’s medical history. The Board acknowledges the Veteran’s belief that the evidence of a suspected heart murmur in service was early evidence of his later diagnosis of coronary artery disease, however he has not been shown to have the requisite expertise necessary to provide a competent opinion on this matter. Therefore, the most probative evidence of record is the VA opinion determining that the Veteran’s current cardiac condition is not related to service. Accordingly, direct service connection is not warranted. Further, the Veteran has not been service-connected for an acquired psychiatric disorder, to include PTSD with alcoholism. As such, service connection on a secondary basis is not supported. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel