Citation Nr: 18151047 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 10-08 616 DATE: November 19, 2018 ORDER Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran does not have a psychiatric disorder, to include PTSD that is related to his military service. CONCLUSION OF LAW The criteria for entitlement to service connection for a psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1967 to January 1988. In August 2014 and January 2017, the Board remanded the claim for additional development. The claim has been returned to the Board for further appellate review. Entitlement to service connection for psychiatric disability Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (a) (2018). 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. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Veteran contends that he has a current psychiatric disorder, to include PTSD that is related to his military service. Specifically, the Veteran has asserted that he has a psychiatric disorder as a result of claimed service in Vietnam and/or as a result of a July 1986 burn injury he incurred in service. Establishing entitlement to service connection for PTSD requires medical evidence diagnosing the condition 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). However, 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 a veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C. § 1154 (b) (2012); 38 C.F.R. § 3.304 (f) (2018). If the Veteran did not serve in combat, or if the claimed stressor is not related to combat, there must be independent evidence to corroborate a Veteran's statement as to the occurrence of the claimed stressor. See Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). Generally, the Veteran's testimony alone cannot establish the occurrence of a non-combat stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Furthermore, an opinion by a medical health professional based on post-service examination of the Veteran cannot be used to establish the occurrence of a stressor. See Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). The Board notes that in August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. The Board will consider the claim with both the DSM-IV and the DSM-V criteria in mind. At the outset, the Board notes that a September 2013 statement from the National Personnel Records Center (NPRC) stated that there is no evidence to substantiate the Veteran’s claim that he served in Vietnam. Therefore, any VA or private diagnosis of PTSD or any other psychiatric condition that is based on the Veteran’s claimed Vietnam combat experiences is deemed inadequate as it is based on inaccurate facts. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions because examiner failed to consider certain relevant information). The Veteran’s service treatment records (STRs) contain evidence that the Veteran received psychiatric treatment several times during his active duty service. In May 1975, a mental health clinic note reflects that the Veteran had a transient depressive reaction due to intense marital discord and possible involuntary separation from the Air Force. A February 1976 statement by a military psychiatrist notes that the Veteran was violent and needed psychiatric treatment after an incident of alleged assault with a deadly weapon against his wife. In April 1978, the mental health clinic assessed acute situational reaction. A December 1986 emergency room (ER) note states the Veteran requested to see a psychiatrist and was assessed with adjustment disorder with depressed mood. The Veteran’s STRs also show that in July 1986 during a barbecue, charcoal lighter fluid briefly flashed up to the Veteran’s right cheek and forearm. The ER note reflects that his right dorsal forearm and hand were singed, with scant blistering at the anticubitum, and 1st and 2nd degree burns to the face and right arm. A follow-up note five days later reflects the Veteran was uncomfortable and had no sign of infection on his arm or face. An August 1986 treatment note shows that the entire burn was epithelialized. Post-service private and VA treatment records show that the Veteran has been treated for and diagnosed with various psychiatric conditions throughout the years. A December 1992 VA examiner was unable to make a diagnosis but noted the Veteran had signs of major depression. At a December 1994 VA examination, the Veteran was diagnosed with schizophrenia, PTSD, alcohol and cocaine dependence, and adult antisocial behavior. A March 1997 private treatment record shows the examiner opined that the Veteran’s psychiatric symptomatology could be attributed to substance abuse rather than a psychotic disorder. A May 1997 VA inpatient record shows the Veteran was admitted due to suicidal ideations. A private examiner diagnosed schizophrenia in December 1998. An April 2004 VA examiner diagnosed psychotic disorder, PTSD, mood disorder, and cocaine abuse. A November 2009 VA PTSD examination reflects that the Veteran reported that he drinks alcohol daily and started using alcohol when he entered the military. He also stated he first started using drugs when he got to Vietnam in 1969 and currently used marijuana and cocaine. The examiner diagnosed polysubstance dependence, chronic. There was no diagnosis of PTSD. The examiner noted the previous diagnoses of PTSD were conferred in a clinical context where different diagnostic guidelines apply, appear to have been based predominantly on the Veteran’s subjective report of symptoms, and were therefore inapplicable to the current exam. At a December 2011 VA examination, based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the examiner diagnosed the Veteran with PTSD, personality disorder, alcohol and cocaine dependence, and psychotic disorder. However, the examiner opined the Veteran’s PTSD was related to his fear of hostile military or terrorist activity, specifically to his reported combat experience in Vietnam. As noted earlier, there is no evidence to substantiate the Veteran’s claim of Vietnam service. Therefore, the December 2011 VA examiner’s diagnosis of PTSD is of no probative value because it is based on a subjective history of trauma grounded in inaccurate facts. In a July 2012 VA opinion, a VA examiner opined that based on the Veteran’s report of service in Vietnam he suffered from PTSD which aggravated his alcohol/drug use. In a March 2013 addendum, the examiner further explained that the Veteran suffered from PTSD which had overlapping symptomatology with his substance abuse disorders. As this diagnosis was improperly based on the Veteran serving in Vietnam, it cannot serve as a basis for a grant of service connection. In an August 2014 Board decision, the issue was remanded for a new VA PTSD examination to determine whether the Veteran has a current psychiatric condition under DSM-IV criteria that is related to his in-service psychiatric treatment or to his in-service burn injury. An April 2016 VA examiner diagnosed the Veteran with alcohol use disorder, cannabis use disorder, cocaine use disorder, substance-induced mood disorder, and substance-induced psychotic disorder. The examiner stated the Veteran’s symptoms do not meet the diagnostic criteria for PTSD under DSM-V, although his reported stressor of being burned in service is adequate to support a PTSD diagnosis. In a January 2017 Board remand, the April 2016 opinion was found to be inadequate as the examiner used DSM-V criteria, however the Veteran’s claim is to be considered under DSM-IV criteria. The issue was remanded for an addendum opinion. In a February 2017 VA addendum opinion, the April 2016 VA examiner opined it was less likely than not the Veteran had a psychiatric condition that was incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that based on the Veteran’s self-report of symptoms, the Veteran does not meet the criteria for a diagnosis of PTSD related to his burn injury or any other substantiated traumatic event. The examiner also stated that the Veteran has been given various psychiatric diagnoses that appear to be primarily due to the variety of symptoms that can be induced with substance abuse, including mood disorders and psychosis, and that additionally, the PTSD diagnoses are often made during treatment of his self-report of symptoms and prior statements in his record. The examiner stated the Veteran’s symptoms can also be explained by his substance abuse. Furthermore, the examiner stated, the Veteran reports inconsistent events that he believes resulted in his claimed PTSD such as reporting chronic problems with flashbacks to Korea and Vietnam where he was a POW, when there is no evidence these events took place. The examiner stated the claimed events may be related to alcohol-related confabulation or drug induced delusional/paranoid symptoms. Accordingly, the examiner noted the primary diagnoses as alcohol use disorder, cocaine use disorder, cannibis use disorder with secondary substance-induced mood disorder and psychosis. The examiner stated the Veteran did not meet the DSM-IV or DSM-V diagnostic criteria for the clinical diagnosis of PTSD based on all the available evidence, and that additionally, the symptoms he reported in the April 2016 VA exam are not consistent and do not substantiate a diagnosis of PTSD. Lastly, the examiner stated previous diagnoses of PTSD in the record are felt to be made erroneously. In a March 2018 independent medical opinion, and after a review of the entire medical record, a Board-Certified Psychiatrist identified the following diagnoses: 1) alcohol use disorder, severe; 2) cannabis use disorder, severe; 3) stimulant use disorder, severe, cocaine; 4) substance induced mood disorder; and 5) substance induced psychotic disorder. The examiner was asked to resolve several questions in the opinion and the Board will take them in turn. First, the reviewer was asked to offer an opinion on whether the Veteran meets DSM-IV or DSM-V criteria for a diagnosis of PTSD based on the conceded stressor of the July 1986 burn injury. As listed above, the reviewer did not find the Veteran has a diagnosis of PTSD. The rationale provided is that the reviewer did not think the relatively mild burn from the barbeque flare-up was a sufficient stressor for DSM criteria A as the intent of that criteria is a truly life threatening or catastrophic event. The reviewer found that the burn suffered from the lighter fluid flash does not meet that criteria as the Veteran’s life was not in danger and his recovery was medically uneventful (there was no gangrene as the Veteran stated, nor was it a gasoline fire set by persons wanting to kill the Veteran as he stated previously). The reviewer opined that the Veteran incorporated this fire flash into his paranoid delusional system and confabulated the intensity and characteristics of the event and his recovery. If PTSD was not found, the reviewer was asked to rationalize such a finding against the Veteran’s treatment records which show a continued diagnosis of and medication for PTSD during the appeal, to include specifically addressing the May 2015 social worker finding that the Veteran suffers from PTSD as a result of his in-service burn injury. The reviewer restated that in their opinion, the Veteran’s burn injury does not meet criteria A for a diagnosis of PTSD and there are no clear iterations or examples of diagnostic criteria that as a whole would support a diagnosis of PTSD. As for the repeated diagnosis of PTSD, the reviewer stated treating clinicians will take a Veteran’s word that he/she has PTSD and they rarely do an in depth diagnostic interview. The reviewer also stated that many, such as social workers, are not trained to that level of detail and clinicians because of time limitations will come up with a working diagnosis not a forensic diagnosis, and will also adopt the diagnosis already in the chart. As an example, the reviewer noted the October 15, 2012 note by Dr. S.S. where he takes over the case from another physician and notes the date and diagnosis from when the Veteran was last seen. The reviewer stated that making a diagnosis of PTSD takes a long time, every criterion has to be explored to make sure it was not preexisting, or that it causes sufficient disability to meet the criteria, and a decision must be made that the symptom is not a manifestation of another disorder. The reviewer went on to state that all the records cited in which the Veteran was diagnosed with or treated for PTSD are treating clinicians who either used preexisting diagnoses in the chart, based their diagnosis on the Veteran’s self-report which in this case is especially problematic since the Veteran is a very poor and unreliable historian, or they used a few criteria to make an erroneous diagnosis. Second, if the diagnosis of major depressive disorder is not found, the reviewer was asked to rationalize such a finding against the Veteran’s treatment records which include continued treatment and medication for the condition. In response, the reviewer noted that the Veteran does not meet criteria C for major depressive disorder which states that the episode is not attributed to psychologic effects of a substance or related to medical conditions. The reviewer stated that clearly the Veteran does not meet the criteria as he has a decades long history of alcohol and polysubstance abuse with no periods of sobriety and a positive urine drug screen for cocaine. The reviewer stated that rather than major depressive disorder, the most likely diagnosis is substance-induced depression. The reviewer went on to state that the use of antidepressants and other classes of medication are non-specific as antidepressants are used for depressive diagnosis, anxiety disorders, obsessive compulsive disorder, bipolar and schizophrenic disorders and many more medical diagnoses such as chronic pain and enuresis, so a certain class of medications does not support a diagnosis. Third, if no diagnosis is provided for any acquired psychiatric disorder, the reviewer was asked to discuss the Veteran’s recurrent psychiatric symptomatology noted throughout the appeal period, with special attention directed to VA and Mobile Infirmary Medical Center Records indicating medication and hospitalization. In response, the reviewer stated the Veteran suffers from decades of alcohol abuse as well as cocaine and marijuana abuse, and there are indications from the claims file that he also abused benzodiazepines. The reviewer noted that since the Veteran is a notoriously poor and unreliable historian, citing his denial of drug use while having a positive urine drug screen for cocaine during his 2017 hospitalization, the extent of his drug abuse may never be known. The reviewer stated a typical pattern for substance abusers is to minimize and even deny use. The reviewer noted the Veteran has a typical pattern of depression, lack of motivation, chronic fatigue, social isolation, divorce, alienation of family, multiple medical and financial concerns, inability to hold a job, suicidal ideation and even attempts which is all reflected in the diagnosis of substance induced mood disorder. Additionally, the Veteran shows the development of paranoia with visual and auditory hallucination, and incorporation of life events into the paranoia or even confabulation of events which is reflected in the diagnosis of substance induced psychotic disorder. The reviewer stated both substance induced mood disorder and substance induced psychotic disorder are well known consequences of chronic substance use disorders. Fourth, for each current diagnosis to include PTSD and/or any other acquired psychiatric disorder present, the reviewer was asked to opine whether it is at least as likely as not the current acquired psychiatric disorder was incurred during the Veteran’s service or as a result of the incident or stressor during service. For the diagnosis of alcohol use disorder, the reviewer opined it is at least as likely as not the Veteran had alcohol use disorder while on active duty, however no in-service stressor was the cause of the development of the disorder. For the diagnosis of substance use disorder, the reviewer opined it is at least as likely as not the Veteran had substance use disorder while on active duty, however no in-service stressor was the cause of the development of the disorder. For the diagnosis of substance induced mood disorder, the reviewer opined it is less likely as not the Veteran had substance induced mood disorder while on active duty and no in-service stressor was involved in the development of this disorder. Lastly, for the diagnosis substance induced psychotic disorder, the reviewer opined it is less likely as not the Veteran had substance induced psychotic disorder while on active duty and no in-service stressor was involved in the development of this disorder. Fifth, the reviewer was asked to address whether the Veteran’s reported 1986 and 1988 in-service conflict aggravated any already present psychiatric disability as his STRs and military personnel records reflect repeat treatment and hospitalization for psychiatric disabilities from May 1975 until March 1987. The reviewer replied that the Veteran by his own admission stated that he drank daily while in service and was starting to show the characteristic problems developed by chronic substance abuse, such as family discord, job difficulties, problems with authority, and poor work performance. The reviewer also stated the addition of valium to alcohol enhances its effects and account for the aggravating difficulties in service. The reviewer opined the difficulties and conflicts in 1986 and 1988 were a result of his chronic substance use disorder. Sixth, as the March 2013 VA addendum opinion suggests the Veteran suffers from an underlying psychiatric disorder beyond his alcohol and drug abuse, the reviewer should address the contentions about separate symptomatology raised by the March 2013 examiner. In response, the reviewer stated that if the 2013 examiner had been told the Veteran was not in combat in Vietnam, he/she would have looked for other reasons for the Veteran’s symptoms, not the least of which would have been the very real possibility the Veteran was confabulating experiences he did not have. The reviewer stated this raises several diagnostic possibilities such as confabulation due to alcohol and drug abuse, sociopathic personality disorder, and confabulation for secondary gain. The reviewer noted that the Veteran continues to refer to himself as a Vietnam war veteran and attribute his medical and psychiatric symptoms to this confabulated experience. The reviewer opined the best explanation for this is drug induced psychosis to include confabulation. Lastly, the reviewer was asked to address the April 2015 finding by Dr. S.S. that the Veteran’s attempt to self-medicate with alcohol likely exacerbated symptoms of PTSD and may be a factor in psychosis, suggesting the Veteran has a psychiatric disability separate from his drug and alcohol abuse. In response, the reviewer pointed out that the psychiatric conditions the Veteran has in addition to his chronic alcohol and drug use disorder are substance induced mood disorder and substance induced psychotic disorder, both of which are directly related to and a consequence of his abuse of substances. The reviewer went on to state it is not uncommon for individuals with substance abuse to turn back to or increase use in response to adverse events or even in response to increasing depression or paranoia that actually stems from their abuse of substances, so in that regard Dr. S.S. is quite right in stating that alcohol may be a factor in psychosis. In summary, the reviewer opined that the Veteran has chronic and severe alcohol use disorder, chronic and severe stimulant (cocaine) use disorder, chronic cannabis use disorder, substance induced mood disorder, and substance induced psychotic disorder. The reviewer stated PTSD or any other psychiatric condition was found and opined that all the Veteran’s symptomatology can be encompassed by the above diagnoses and these diagnoses are consistent with the Veteran’s history, known natural course of said illnesses, and good medical practice. The Board finds the March 2018 independent medical opinion to be of high probative value as the reviewer gave definitive conclusions and supported the given opinion by rationale that considers all the evidence of record in concert with the reviewers over 40 years of medical experience. The Board has taken into account the lay statements that the Veteran has presented in this claim. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a diagnosis and etiology of a psychiatric disorder, to include PTSD, falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms, any actual diagnosis of PTSD or any other acquired psychiatric disorder requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Moreover, service connection for PTSD specifically requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (2018). After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that the Veteran has a current diagnosis of PTSD consistent with either the DSM-IV or the DSM-5, or any other psychiatric disorder that is related to service. Although several VA treatment and private record entries reflect a diagnosis of PTSD, the weight of the evidence is against a finding that the Veteran has a current diagnosis of PTSD for VA compensation purposes. See 38 C.F.R. § 3.304 (f); see also 38 C.F.R. § 4.125 (a) (2018) (stating that the diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, of the American Psychiatric Association (DSM-IV)); 38 C.F.R. § 4.125 (a) (2018) (stating that the diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, of the American Psychiatric Association (DSM-5)). For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a current diagnosis of PTSD, or any other psychiatric disorder related to service, in accordance with the DSM-IV or DSM-5 criteria as required under 38 C.F.R. § 4.125(a). As such, service connection for a psychiatric disorder, to include PTSD, is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Mitchell, Associate Counsel