Citation Nr: 18150256 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-38 188 DATE: November 14, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include major depression with anxiety is denied. Entitlement to service connection for coronary artery disease is granted. FINDINGS OF FACT 1. An acquired psychiatric disorder, diagnosed as major depression with anxiety, did not have its onset in service and is not shown to be etiologically related to the Veteran’s active service. 2. Resolving doubt in the Veteran’s favor, the Veteran’s CAD is related to service. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include major depression with anxiety was not incurred in or aggravated by active service. 38 U.S.C. §§ 1101, 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). 2. The Veteran’s CAD was incurred in service. 38 U.S.C. §§ 1101, 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from June 1973 to June 1993. With regard to the Veteran’s acquired psychiatric disorder claim, the Board acknowledges that the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any psychiatric disability that may reasonably be encompassed by a veteran’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A review of the record reveals that the Veteran has been diagnosed with major depression with anxiety. In light of the Court’s holding in Clemons, the Board has recharacterized the Veteran’s claim as entitlement to service connection for an acquired psychiatric disorder, to include major depression with anxiety. 1. Acquired Psychiatric Disorder The Veteran contends that he has an acquired psychiatric disorder that is related to his service. Veterans are entitled to compensation from VA if they develop a disability “resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty.” 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). After the evidence is assembled, it is the Board’s responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. With respect to a current disability, the Board notes that the current medical evidence of record documents treatment for major depression as well as anxiety. See, e.g., a June 2013 VA examination report. The Board acknowledges the Veteran’s report that in addition to major depression and anxiety, he suffers from bipolar disorder. However, the medical evidence is absent such a finding. In this regard, the June 2013 VA examiner concluded after examination of the Veteran and consideration of his medical history that the Veteran does not have bipolar disorder. The Board notes that S.M., APN diagnosed the Veteran with bipolar disorder in a March 2007 private treatment record. Although not disparaging the qualifications of S.M., APN, see Goss v. Brown, 9 Vet. App. 109 (1996), his qualifications are less impressive than those of the June 2013 VA examiner, a VA clinical psychologist, who specifically did not report that the Veteran suffered from bipolar disorder. See Black v. Brown, 10 Vet. App. 297, 284 (1997) [in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data]. Further, S.M., APN failed to provide a rationale as to why the Veteran’s symptoms constituted a diagnosis of bipolar disorder. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) [the failure of the health care provider to provide a basis for his/her opinion goes to the weight or credibility of the evidence]. On the contrary, as discussed above, the June 2013 VA examiner reviewed the Veteran’s available service records as well as the Veteran’s entire medical history, and concluded that the evidence of record, to include examination of the Veteran, did not support a diagnosis of bipolar disorder. Accordingly, the Board finds that the diagnosis of bipolar disorder rendered by S.M., APN is of no probative value with regard to whether the Veteran has had bipolar disorder at any time during the pendency of his claim. The Board also observes that the Veteran’s attorney has submitted medical articles pertaining to the development of bipolar disorder in relation to incidents during the Veteran’s service and after service. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. However, the articles submitted by the Veteran’s attorney are of a general nature and do not contain any information or analysis specific to the Veteran’s case. Additionally, the Court has held that medical evidence which is speculative, general, or inconclusive in nature cannot support a claim. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). As discussed in detail above, the June 2013 VA examiner reviewed the Veteran’s medical history, considered his complaints, and conducted an examination of the Veteran, and thereafter concluded that the Veteran does not have bipolar disorder. The Board has therefore placed great probative value on the findings of the VA examiner. As such, the medical articles submitted by the Veteran’s attorney are of little or no probative value, and, to the extent that there is any probative value, is greatly outweighed by the examiner’s opinion. With regard to in-service incurrence of an injury or disease, the Veteran’s service treatment records are absent complaints of or treatment for an acquired psychiatric disorder. However, the Veteran reported in a statement dated September 2018 that he had multiple incidents of having difficulty getting along with other soldiers as well as marital difficulty during service. Indeed, a service treatment record dated December 1979 documents the Veteran’s marital problems with his wife and that they had marital counseling. The Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record supports a finding that the Veteran’s acquired psychiatric disorder is not related to his service. Specifically, the Veteran was afforded a VA psychological examination in June 2013. Notably, the examiner considered the Veteran’s report of history of mental health symptomatology. After examination of the Veteran and consideration of his medical history, the VA examiner diagnosed the Veteran with major depression with anxiety and concluded that it is less likely than not that the Veteran’s current major depression with anxiety is related to service. The examiner’s rationale for her conclusion was based on her finding that it is more likely than not that the Veteran’s current major depression and anxiety is due to a progression of situational stressors not connected to service as well as lifelong aberrant personality traits and behaviors. The June 2013 VA examination report was based upon thorough review of the record, thorough examination of the Veteran, and thoughtful analysis of the Veteran’s entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Additionally, the VA examiner’s opinion is consistent with the Veteran’s documented medical history, which is absent any report of symptomatology of an acquired psychiatric disorder for more than 2 years after service. The Veteran has not submitted a competent medical opinion to contradict the VA examiner’s opinion that his acquired psychiatric disorder is not related to service. The Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has not done so. See 38 U.S.C. § 5107(a) (2012) (it is the claimant’s responsibility to support a claim for VA benefits). In relevant part, 38 U.S.C. 1154(a) (2012) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). “Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including depression), has presented no clinical evidence of a nexus between his diagnosed psychiatric disorder and his service. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to service. Such opinion requires specific medical training in the field of mental health and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training in the field of mental health to render medical opinions, the Board must find that his contention with regard to a nexus to be of minimal probative value and outweighed by the objective evidence which is absent a finding of such. See also 38 C.F.R. § 3.159(a)(1) (2017) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a nexus. Accordingly, a nexus is not met, and the Veteran’s claim fails on this basis. In conclusion, for reasons and bases expressed above, the Board finds that a preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include major depression with anxiety. The benefit sought on appeal is therefore denied. 2. CAD With regard to the Veteran’s claim of service connection for coronary artery disease, the Veteran contends that he has coronary artery disease that is related to service, to include his in-service complaints of chest pain and high cholesterol. Although the Board notes the Veteran’s service treatment records are absent complaints of or treatment for coronary artery disease, chest pain was documented on multiple occasions throughout the Veteran’s service. Further, the Veteran’s March 1993 retirement examination indicates a finding of high cholesterol, and subsequent postservice treatment records continued to document such. The Board observes that there are conflicting medical opinions of record as to whether the Veteran’s current coronary artery disease is related to service. Specifically, in a VA opinion report dated July 2016, the VA examiner concluded after review of the Veteran’s medical history that it is less likely than not that the Veteran’s current coronary artery disease is related to service, to include the findings of high cholesterol, chest pains/pressure in chest, sinus bradycardia, and/or complaints/conditions noted during service. The examiner’s rationale for his conclusion was based on his finding of no documentation of coronary artery disease until 2006 which was 13 years after the Veteran’s separation from service. He also noted that the actual basis for the Veteran’s chest pains such as GERD, costochondritis, and musculoskeletal chest pain are not cardiac in nature nor do they predispose one to develop coronary artery disease. Moreover, by the time the Veteran had his coronary artery disease in 2006, he had the other risk factors of male sex, hypertension, family history of premature coronary artery disease, age greater than 50, and peripheral vascular disease that alone or in concert would have resulted in the development of his coronary artery disease. Finally, the Veteran’s sinus bradycardia refers to a slow heart rate and is not specific or conclusive for coronary artery disease as there are many causes for it. Pertinently, the VA examiner did not address in his rationale why the Veteran’s current coronary artery disease is not related to the in-service findings of high cholesterol and the postservice documentation of such. Also, the Board notes a medical article submitted by the Veteran’s attorney indicating coronary artery disease occurs over time and therefore the Veteran evidences symptoms of coronary artery disease such as high cholesterol which eventually caused the diagnosed disability in 2006. The Board further notes that the medical evidence documents the Veteran underwent 9 stents between 2006 and 2007 which were not addressed by the VA examiner in his rationale. The Board acknowledges that another VA examiner opined in a June 2013 report that it is at least as likely as not that the Veteran’s current coronary artery disease was incurred in or caused by service. The examiner’s rationale for his conclusion was based on the in-service findings of high cholesterol as well as the 9 stents that the Veteran underwent. However, the examiner did not address findings of the July 2016 VA examiner such as the other risk factors of coronary artery disease which include male sex, hypertension, family history of premature coronary artery disease, age greater than 50, and peripheral vascular disease that alone or in concert could have resulted in the development of the Veteran’s coronary artery disease. The June 2013 VA examiner also did not address the period of 13 years from the Veteran’s discharge until the initial diagnosis of coronary artery disease. In view of the circumstances, the Board resolves all reasonable doubt in favor of the Veteran and finds that the evidence is at least in equipoise. As such, service connection for the Veteran’s CAD is warranted. Biswajit Chatterjee Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Arif Syed, Counsel