Citation Nr: 18150416 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 18-39 021 DATE: November 15, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The Veteran does not have a current disability of PTSD. 2. The Veteran has been diagnosed with adjustment disorder, with anxiety and depression. 3. The Veteran’s adjustment disorder, with anxiety and depression was not incurred in, nor was it caused by any aspect of service; rather it was caused by a non-service connected disability and other life events. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1969 to December 1971 in the United States Army with combat service in the Republic of Vietnam. His military occupational specialty (MOS) was a Medical Corpsman. He was awarded the Army Commendation Medal with combat “V” and the Combat Medical Badge. This current appeal comes to the Board of Veterans’ Appeals (Board) from an April 11, 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. Duty to Notify and Assist Neither the Veteran nor his representative identified any shortcomings in fulfilling VA’s duty to notify and assist. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board thus finds that further action is unnecessary under 38 U.S.C. § 5103A and 38 C.F.R. § 3.159. The Veteran will not be prejudiced because of the Board’s adjudication of the claims below. Service Connection Generally, to establish service connection 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 incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any or 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 the absence of proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability in accordance with the DSM-IV for claims certified for appeal before August 4, 2014, and DSM-5 for claims after that date, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f), 4.125(a). As with all claims for service connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In order to receive entitlement to service connection for PTSD, the evidence must demonstrate a diagnosis in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f)(1); see also 38 U.S.C. § 1154 (b) and 38 C.F.R. § 3.304 (d) (pertaining to combat Veterans). A finding that the Veteran engaged in combat with the enemy, however, requires that the Veteran participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality, and does not apply to veterans who served in a general “combat area” or “combat zone” but did not themselves engage in combat with the enemy. See VAOPGCPREC 12-99 (October 18, 1999). As this matter was certified to the Board on August 28, 2018, the DSM-5 applies. PTSD Service treatment records (STRs) do not show any psychiatric symptoms, diagnoses, or treatment during active service. The Veteran denied any psychiatric issues during a separation physical examination. A primary care intake-note, from May 7, 2013, showed a negative PTSD screening. His depression screening was also negative. When asked if he had little interest or pleasure; or if he felt depressed or hopeless, he responded “Not at all.” He denied nightmares, avoidance, being easily startled or watchful, and said he did not feel numb or detached from others or his surroundings. On January 26, 2016, the Veteran had a positive PTSD screening. He endorsed nightmares, avoidance, said he was easily startled and on guard, and that he felt numb or detached from others and his surroundings. In a compensation and pension (C&P) examination on March 17, 2016, the examiner noted the two contradictory screenings from 2013 and 2016 and found that the Veteran did not meet the criteria for PTSD. He was diagnosed unspecified anxiety and depressive disorders. The disorders caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally he functioned satisfactorily, with normal routine behavior, self-care and conversation. The examiner noted the Veteran’s MOS and combat involvement. The Veteran reported that his mental health symptoms began after he had a stroke in 2001. His symptoms included: Inability to talk “for a couple of hours,” depressed mood, probable nightmares (as reported by wife—“tosses and turns, and yells out, hits in sleep—she sleeps in a separate bedroom), periodic fatigue, suspiciousness of others, lack of interest in leisure activities, and social isolation. The Veteran was seen for his mental health on September 13, 2016. He told the physician that his mental health was getting worse, and that he believed this was due to his other health issues. He said he was frustrated and depressed that he did not have a service connected disability for his psychiatric condition, the examiner noted that the Veteran “somehow likely believes the percentage and pay would be substantial” if he were service connected. The Veteran was fully oriented, his speech and thought were good, he was logical and goal oriented with normal psychomotor activity, his mood was mildly depressed with a congruent affect; he denied hallucinations, delusions, and suicidal and homicidal ideations. His insight and judgment were fair, and he was not a danger to himself or others. On December 14, 2017 the Veteran reported an additional stressor. He reported that sometime in 1971 his infantry unit was exposed to enemy artillery and hand grenade attacks while on patrol. He did not explain in detail because he said it was “too traumatic to discuss in writing.” In a March 28, 2018 C&P examination, the examiner did not find that the Veteran met the criterion for PTSD, but did diagnose adjudgment disorder with mixed anxiety and depression. The diagnoses were attributed to family deaths, poor physical health (stroke, leg cramps, insomnia), and work. He was also diagnosed with a severe alcohol use disorder that was in remission for one year. The diagnoses were found to cause occupational and social impairment due to mild or transient symptoms with decreased work efficiency and inability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. It was also recorded that the Veteran’s physical health prevented him from participating in activities. The examiner noted that mental health services began in 2016, and the Veteran was seeing a psychiatrist every 3-months. His anxiety and depression were related to his stroke in the early 2000s. The Veteran said he did not think he was mentally ill, because if he were, he would not be working. He expressed concern about possibly having cancer. As for stressors, the examiner noted “vague references to 3 incidents in Vietnam while operating as a ‘combat medic.’ In one incident a grenade exploded some distance from him and others.” This was found to meet the first criterion for PTSD and be related to a fear of hostile military or terrorist activity. However, the Veteran did not meet criterion B, C, D, F, or G. He had symptoms of depression, anxiety, chronic sleep impairment, mild memory loss, circumstantial, circumlocutory or stereotyped speech, and disturbed motivation and mood. The behavioral observations were as follows: Indications of resistance throughout the interview. Admitted to a dislike of being asked personal questions. Admitted a general distrust of mental health practitioners. Very vague answers to most questions . . . Focus & attention given to stress associated with physical condition (post-stroke condition, cancer). Talked about death of siblings & brother-in-law (recent). The examiner made the following remarks: He denied a “mental illness,” and does not want to see a counselor. He admitted to physical health concerns that are causing psychological distress (chronic worrying, fears, sadness, stress reactions) . . .. Another source of distress is the situation with his work. He continues to work 40hrs./week, but doesn’t enjoy the work environment. He also admitted the fear or being diagnosed with cancer increased his anxiety. In finding that the Veteran’s psychiatric disabilities were less likely than not related to military service, the examiner concluded Veteran’s current diagnosis meets DSM criteria, but there is no evidence that it is related to the Veteran’s military service. There is no report of mental health issues during the Veteran’s service time and no consistent report of ongoing mental health problems since military service until 2017, when first seen for mental concerns. Therefore, there is no nexus between military service and current symptoms. Analysis Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a). While the Veteran’s MOS shows that his claimed stressor is consistent with the conditions of his service he cannot be granted service connection for PTSD as he has not been diagnosed with PTSD according to the DSM-5 criterion. However, he has been diagnosed with adjustment disorder, with anxiety and depression and entitlement to service connection for these diagnoses must be analyzed. For the reasons to follow, the Veteran is not entitled to service connection for his psychiatric disabilities. The Veteran separated from service in 1971, upon separation he denied any psychiatric issues. He has explained several times that his current stress, depression, and anxiety were onset after he suffered a stroke in 2001. Although he once stated that he began receiving mental health treatment “10 to 15 years ago” the contemporaneous medical evidence does not show that treatment began until approximately 2015. In 2013 he denied any depressive symptoms or PTSD, and still today he states that he does not have a mental illness. His wife explained that the Veteran has had PTSD symptoms since they were married in 1973, but they worsened after the stroke. While she and the Veteran are competent to report symptoms of PTSD the report of symptoms is not consistent with the contemporaneous medical evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (the Board must take into account self-reported inconsistencies when stacked against contemporaneous medical evidence). Along with the inconsistent reporting, the Veteran did not report symptoms until 2016, which is 45 years after separation. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007). In addition to the Veteran consistently endorsing that his symptoms were onset by a stroke in 2001, and have worsened as his physical health deteriorates, the two C&P examinations both found that his psychiatric disabilities were not service related. The examiners drew their conclusions based on the Veteran stating that his depression and anxiety began after his stroke in 2001. It should also be noted that although the Veteran and his wife say he is often socially isolated this statement is not consistent with his May 2013 statement that denied isolation or detachment. Additionally, the examiners found that physical, non-service connected disabilities caused inactivity rather than any psychiatric symptoms hindering his activity. Several times before and since the start of this appeal the Veteran said that his psychiatric symptoms began after a stroke. He has also stated that his deteriorating physical health has caused worsening psychiatric symptoms; and even told one examiner that compensation from service connection would help alleviate the stress. The Board finds these statements are consistent, competent, and credible and therefore assigns them weight; whereas his reporting of symptoms onset since Vietnam are not credible as they are not backed up by contemporaneous medical evidence. Caluza, 7 Vet. App. at 511. There is also no competent medical evidence that has linked the Veteran’s adjustment disorder, with anxiety and depression to his military service. Based on these findings, the Board denies entitlement to service connection for an acquired psychiatric disorder, to include PTSD. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Harner, Associate Counsel