Citation Nr: 18158218 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 13-32 378 DATE: December 14, 2018 ORDER Entitlement to service connection posttraumatic stress disorder (PTSD) with alcohol use disorder, is granted. Entitlement to service connection for a gastrointestinal disability, to include irritable bowel syndrome (IBS), secondary to service-connected PTSD, is granted. Entitlement to service connection for erectile dysfunction (ED), secondary to service-connected PTSD, is granted. Entitlement to a disability rating in excess of 10 percent for external hemorrhoids is denied. REMANDED Entitlement to a separate compensable rating for impaired sphincter control is remanded. Entitlement to service connection for residuals of pseudofolliculitis barbae is remanded. FINDINGS OF FACT 1. The evidence of record favors a finding that the Veteran has PTSD with alcohol use disorder that is proximately due to his active service. 2. The Veteran’s IBS is aggravated by his service-connected PTSD. 3. The Veteran’s ED is aggravated by his service-connected PTSD. 4. The Veteran’s service-connected hemorrhoids disability, at worst, has been manifested by frequent occurrences of internal and external hemorrhoids that result in persistent rectal bleeding, constipation, itching, pain and swelling, but without evidence of secondary anemia or fissures. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD, with alcohol use disorder, have been met. 38 U.S.C. §§ 1110, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for IBS, secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 3. The criteria for service connection for ED, secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. The criteria for a rating in excess of 10 percent for external hemorrhoids have not been met. 38 U.S.C. 1155, 5107 (West 2012); 38 C.F.R. 3.321, 4.1, 4.3, 4.7, 4.114, DC 7336 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to November 1970 and from September 1974 to November 1986. Additionally, he served in the United States Naval Reserves from November 1970 to September 1974. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). Generally, in order to prove 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). Service connection may also be established on a secondary basis for a disability that is proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). 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). 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) Establishing service connection for PTSD generally requires (1) evidence of a current medical diagnosis of PTSD, (2) credible supporting evidence that the claimed in-service stressor actually occurred, and (3) medical evidence of a link between the claimed in-service stressor and the current PTSD symptoms. 38 C.F.R. § 3.304(f). The Veteran has been diagnosed with PTSD, with alcohol use disorder. He contends that his claimed trauma was related to physical abuse and military hazing that he experienced during active service. In August 2013, the Veteran underwent psychiatric examination. The examiner indicated that he did not meet the full criteria for a PTSD diagnosis, but diagnosed him with depressive disorder. The examiner did not, however, reconcile the Veteran’s prior diagnoses of PTSD and PTSD-like symptoms of record with the August 2013 findings. Subsequent to this examination, the Veteran’s VA and private treatment records continued to intermittently reflect diagnoses of PTSD and PTSD-like symptoms. Therefore, in December 2017, the Board remanded the issue to obtain new VA examination. In a February 2018 VA psychiatric examination, the Veteran was diagnosed with PTSD, with a secondary alcohol use disorder. The examiner noted that the Veteran experienced occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran had a history of previous mental health diagnoses of PTSD, anxiety, depression, alcohol use and sleep problems. The examiner opined that it is at least as likely as not that the Veteran’s PTSD, and secondary condition of alcohol use disorder, was caused by the traumatic events that included military hazing and abuse, while serving in the Navy in 1970 and 1979. It is noted that there is a positive nexus opinion of record that is based on a correct reading of the Veteran’s medical history. The Board finds that the February 2018 opinion constitutes competent, probative evidence on the medical nexus question. Therefore, as noted by the examiner, the Veteran’s current acquired psychiatric disorders are associated with his active duty service, and the Board finds no adequate basis to reject this supportive opinion. Thus, entitlement to service connection for an acquired psychiatric disorder, to include PTSD with alcohol use disorder, is warranted. 2. Entitlement to service connection for a gastrointestinal disability, to include irritable bowel syndrome (IBS) 3. Entitlement to service connection for erectile dysfunction (ED) The Veteran contends that his currently diagnosed IBS and ED are related to service, or in the alternative, secondary to his service-connected disabilities. In the Board’s December 2017 remand directives, the regional office (RO) was to obtain VA examination on the Veteran’s behalf. Based on February 2018 VA examination and opinions, the Veteran is now service connected for PTSD, and the examiner found a connection between his PTSD, IBS and ED. As the Veteran has, above, been awarded service connection for PTSD, the Board must now consider whether his currently diagnosed IBS and ED are secondary to his service-connected PTSD. In the Veteran’s February 2018 intestinal conditions VA examination, the examiner diagnosed the Veteran with IBS and indicated that symptoms of alternating constipation, diarrhea, gas, cramping and bloating began in service. He opined, however, that the Veteran did have motion sickness while on his ship in the Navy, but the motion sickness was resolved after he was no longer on the ship. Additionally, the examiner indicated that the Veteran reported being very stressed while in service, especially when his ship was outside of Vietnam during the Vietnam War. Based on the Veteran’s earlier evaluation for PTSD, the examiner noted that he continued to have high stress level since the Vietnam War and military service, and the stress level caused him to have an increase in his peristalsis in his gastrointestinal tract, resulting in IBS, alternating diarrhea and constipation. The examiner concluded that stress also affects the Veteran’s sexual intercourse, which he is not able to achieve or maintain an erection. It is noted that there is a positive nexus opinion of record that is based on a correct reading of the Veteran’s medical history. The Board finds that the February 2018 examiner’s opinion constitutes competent, probative evidence on the medical nexus question. This opinion provides a thorough analysis of the Veteran’s past and current symptoms. Therefore, as noted by the examiner, the Veteran’s current IBS and ED are related to his service-connected PTSD, and the Board finds no adequate basis to reject this supportive opinion. Thus, entitlement to service connection for IBS and ED, secondary to service-connected PTSD, is warranted. Increased Ratings 1. Entitlement to an increased disability rating in excess of 10 percent for external hemorrhoids Disability ratings are determined by evaluating the extent to which the Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes (DCs). 38 C.F.R. § 4.27. The Veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The Veteran’s hemorrhoids have been evaluated as noncompensable since September 26, 2001, and evaluated as 10 percent disabling since May 28, 2004, under 38 C.F.R. 4.114, DC 7336. Under that code, a 10 percent rating is assigned for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A maximum 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. The evidence of record shows that, since February 12, 2012, the Veteran has experienced frequent occurrences of internal and external hemorrhoids with difficulty with constipation, some blood on toilet paper, and skin irritation when he wipes. See February 2012 VA Emergency Department note. However, the RO indicated in a September 2013 rating decision that there is evidence of a May 28, 2004 outpatient treatment record indicating that the Veteran’s hemorrhoids were large. As this rating decision assigned a 10 percent rating for external hemorrhoids, effective May 28, 2004, the Board will not disturb the evaluation of a 10 percent rating, effective May 28, 2004. In a November 2001 VA examination, the examiner indicated that there was no evidence of fissure or fecal leakage; there were external hemorrhoids at 6 o’clock, not thrombosed, and no evidence of bleeding. The Veteran’s abdomen was normal in shape, soft, non-tender; there were no organomegaly or masses; no free fluid; and his bowel sounds were well heard. A February 2012 VA Emergency Department note indicated that the Veteran complained of abdominal pain, difficulty with constipation, some blood on toilet paper, and skin irritation when he wipes. The examiner noted an impression of non-thrombosed external hemorrhoids; noted the sigmoid colon, descending colon, transverse colon, hepatic flexure, and ascending colon were all normal. In a September 2013 VA examination, the examiner found mild or moderate external hemorrhoids, which were large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. The Veteran claimed symptoms of intermittent rectal bleeding. A September 2015 VA examination confirmed the presence of internal and external hemorrhoids. The Veteran reported symptoms of blood in stool, bleeding in the rectum, and uncomfortable bowel movements. The examiner noted mild or moderate internal or external hemorrhoids; found that the Veteran had an anal/perianal fistula with constant slight leakage; and found that there was impairment of the rectal sphincter control leading to occasional involuntary bowel movements. The Veteran was most recently afforded VA examination in February 2018. The Veteran reported that it was hard to sit when having flare-ups. The examiner determined that the Veteran had active external hemorrhoids, that were mild or moderate. Based on the foregoing, there is no evidence showing the Veteran’s hemorrhoids have been manifested by secondary anemia or fissures, which is required to warrant a higher, 20 percent rating under DC 7336. Indeed, even during exacerbations of his disability, there is no lay or medical evidence showing increased symptomatology or manifestations that more nearly approximate the level of disability contemplated by the 20 percent rating under DC 7336. Therefore, the Veteran’s noncompensable rating, since September 26, 2001, and 10 percent rating, since May 28, 2004, must remain; and a rating higher than 10 percent for external hemorrhoids, under DC 7336, is denied. REASONS FOR REMAND 1. Entitlement to a separate compensable rating for impaired sphincter control. The September 2015 VA examiner indicated that there was impairment of the Veteran’s rectal sphincter control, leading to occasional involuntary bowel movements, which is related to his hemorrhoid diagnosis. However, the examination does not contain enough information to rate this possibly separate disability. As such, a remand is necessary to determine the current severity of the Veteran’s impaired sphincter control. 2. Entitlement to service connection for residuals of pseudofolliculitis barbae is remanded. The Veteran contends that he continues to suffer from residuals of the pseudofolliculitis barbae diagnosed in service. Service Treatment Records (STRs) reveal that the Veteran was diagnosed with pseudofolliculitis barbae in July 1986. However, based on the date of diagnosis in service, the RO found that he was barred from receiving any compensation benefits due to the character of discharge for the relevant period of active duty service. See February 2015 Rating Decision. In December 2017, the Board determined that the Veteran was recommended for discharge under other than honorable conditions following an Administrative Board proceeding, which found misconduct due to the commission of a serious offense; a violation of Article 92, failing to obey a lawful order between May 22 and 28, 1986. The Administrative Board also found that he committed misconduct by abusing drugs based on a May 1986 positive urinalysis for cocaine. Pursuant to 38 C.F.R. § 3.12(a), compensation is not payable unless the period of service on which the claim is based was terminated by discharge or release under conditions other than dishonorable. 38 U.S.C. § 101(2) (2012). A discharge or release from service due to willful and persistent misconduct is considered to have been issued under dishonorable conditions. 38 C.F.R. § 3.12(d)(4) (2017). However, if a veteran was insane at the time of committing the offense that caused the discharge or release, then compensation is not barred. 38 C.F.R. §§ 3.12(b), 3.354 (2017). The Board remanded the issue to obtain a VA medical opinion regarding the Veteran’s sanity at the time he committed the offenses for which he was discharged. A February 2018 VA psychiatric examiner determined that, based on his evaluation and a review of the records provided, it is at least as likely as not that the Veteran's mental health condition of PTSD, which was related to traumatic events he experienced in 1970 in 1979, met the definition for insanity pursuant to 38 C.F.R. § 3.354 in May 1986 when he was charged with serious misconduct, which led to his discharge under dishonorable for VA purposes. The examiner further noted that the Veteran had received two different honorable discharges from the Navy in 1976 and in 1981, but as a result of the progression of his PTSD and secondary condition of alcohol and drug use, his behavior departed from the accepted standards and practices he had previously demonstrated in the military environment. As the Veteran was deemed insane at the time of committing the offense that caused the discharge or release, compensation is not barred, and VA examination is warranted to determine whether the Veteran currently has residuals of pseudofolliculitis barbae that are the result of his July 1986 in-service pseudofolliculitis barbae diagnosis. The matter is REMANDED for the following action: 1. Schedule the Veteran for VA examination assess the current severity of his impaired sphincter control. 2. Schedule the Veteran for VA foot examination with an appropriate examiner. The claims file should be made available to, and reviewed by the examiner. Provide answers to the following: Does the Veteran have current pseudofolliculitis barbae residuals? If so, is it at least as likely as not (50 percent or greater probability) that the Veteran’s current pseudofolliculitis barbae residuals began in service, or are otherwise the result of a disease or injury in service, to include his July 1986 in-service diagnosis of pseudofolliculitis barbae? In offering any opinion, the examiner must consider the full record, to include the Veteran’s credible lay statements and hearing testimony. The rationale for any opinion offered should be provided. 3. Readjudicate the appeal, to include granting service connection for any disabilities shown to be secondary to the Veteran’s service-connected hemorrhoids. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD I. Warren, Associate Counsel