Citation Nr: 1815278	
Decision Date: 03/13/18    Archive Date: 03/19/18

DOCKET NO.  09-26 342	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Montgomery, Alabama


THE ISSUE

Entitlement to service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD) with depression.


REPRESENTATION

Appellant represented by:	The American Legion


ATTORNEY FOR THE BOARD

J.N. Moats, Counsel


INTRODUCTION

The Veteran served on active duty in the Army from August 1966 to October 1969 and in the Army National Guard from March 1979 to March 1980.

This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama.

In April 2014, the Board remanded the appeal for further development.  In a February 2016 decision, the Board denied the Veteran's claim for entitlement to service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD) with depression.  The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court).  In December 2016, the Court granted a Joint Motion for Partial Remand (JMR) filed by representatives for both parties, vacating the Board's decision, in part, and remanding the claim to the Board for further proceedings consistent with the JMR.

In March 2017 and August 2017, the Board remanded the issue for further development consistent with the Court order.  The Board finds that there has been substantial compliance with its prior remand directives.  See Stegall v. West, 11 Vet. App 268 (1998).


FINDING OF FACT

Hypertension is not proximately due to or aggravated by the Veteran's service-connected PTSD with depression.


CONCLUSION OF LAW

The criteria for service connection for hypertension as secondary to the Veteran's service-connected PTSD with depression have not been met.  38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017).



REASONS AND BASES FOR FINDING AND CONCLUSION

I.  VA Duties to Notify and Assist

With respect to the claim decided herein, the Veteran has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed.Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board).

II.  Analysis

The Veteran is seeking service connection for his hypertension as secondary to PTSD with depression.  Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C.A. § 1110; 38 C.F.R.  § 3.303(a).  Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury.  Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)].

Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes mellitus, type II, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service.  38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.  

Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service.  See 38 C.F.R. § 3.303(b).  However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint.  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  In this case, as the Veteran's erectile dysfunction are not one of the diseases enumerated under 38 C.F.R. § 3.309(a), service connection may not be established based on a showing of continuity of symptomatology alone and a medical nexus is required.   

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury.  38 C.F.R. § 3.310(a).  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

By way of background, in April 2014, citing a number of studies indicating an association between PTSD and poor cardiovascular health, the Board remanded the case as it found that a VA examination was needed to address whether the Veteran's hypertension is secondary to his PTSD with depression.  The Veteran underwent a VA examination in October 2014.  The examiner's report notes that the Veteran was diagnosed with hypertension in 2002.  "The Veteran was started on medication for hypertension when he entered care in the VA system in 2002.  Although he was diagnosed with PTSD in 2007, mental health notes clearly indicate symptoms of PTSD immediately following service in Vietnam.  He has not had...heart disease."  He takes continuous medication.  After reviewing the Veteran's claims file and a physical examination, the examiner found that the hypertension was not caused or aggravated by the Veteran's PTSD.  The examiner rationalized that "I am unaware or any peer reviewed medical literature which indicates that PTSD causes or aggravates hypertension. [The] Veteran had symptoms of PTSD for 30 years or more prior to diagnosis of hypertension. In addition, treatment for PTSD...does not aggravate hypertension." 

Subsequently, in a January 2016 brief, the Veteran's representative mentioned a report submitted by the Veteran from the National Heart Foundation of Australia addressing the relationship between PTSD and hypertension.  Second, the representative asserted that "Veterans with a history of PTSD had increased odds of having hypertension."  Third, the representative argued that "according to VHA" it has been shown that "essential hypertension is frequently of a multifactorial etiology [and] it was not possible to state that PTSD caused or aggravates the Veteran's hypertension."  Fourth, the representative wrote, "According to the Veteran's Health Council (2009), research studies have also demonstrated that PTSD is linked with co-occurring physical illnesses such as hypertension."  

Nevertheless, the Board denied the Veteran's claim in February 2016 relying on the October 2014 VA examination and finding that the representative's assertions did not support a finding of service connection as they were not specific to the Veteran or his situation and did not provide general evidence of a direct relationship between hypertension and PTSD.  However, the JMR noted that the evidence submitted by the Veteran's representative was not discussed in light of its effect on the probative value of the October 2014 VA examiner's opinion.  In addition, the JMR found that there was no discussion whether the medications prescribed to the Veteran to treat his service-connected PTSD could have caused or aggravated his hypertension, and more specifically, whether the evidence of record was sufficient to render this finding.  Thus, the Board remanded the case to obtain another medical opinion to specifically consider the literature cited to by the Veteran's representative as well as the effect of the Veteran's PTSD medication on hypertension.

An opinion was obtained in April 2017.  The examiner opined that the Veteran's hypertension was not caused by or aggravated by his service-connected PTSD with depression.  The examiner rationalized that the Veteran was diagnosed with hypertension in 2002 and has been treated with medications since that time.  The consensus of the medical literature does not indicate that PTSD causes or aggravated hypertension.  The VA clinical records do not indicate any current medications for PTSD.  Medications for PTSD do not cause or aggravate hypertension.  According to the Mayo Clinic, for most adults, there is no identifiable cause of hypertension.  It tends to develop gradually, often diagnosed in males by middle age.  Risk factors include age, race, lack of physical activities, being overweight, and excessive alcohol use.  At the time of diagnosis, the Veteran reported daily ingestion of alcohol and his liver function test suggested excessive alcohol use.  The examiner had reviewed the cited article and her opinion remained unchanged.  

However, the Board again found that this opinion was inadequate because the examiner did not address the Veteran's PTSD medications, especially the two medications - citalopram hydrobromide (Celexa) and Trazadone - that have been used to treat the Veteran's PTSD, and cited three sources as support for the contention that these medications indicate side effects that may include hypertension.  

Another opinion was obtained in September 2017.  The examiner reviewed all VA medications from 2002 to present that pertained to PTSD and depression and outlined such medications.  However, the examiner observed that currently the Veteran was not on any psychiatric medications for the PTSD and depression.   The Veteran came to PTSD groups, but was not prescribed any medications.  The examiner outlined the side effects of the Veteran's medications specifically with respect to any hypertension.   After review of the articles, the examiner observed that when these side effects occur, they are usually manifested in relation to the    medication.  In this case, review of the Veteran' blood pressure charting showed that there was no hypertensive urgency or elevation that would suggest a side effect from the psychiatric medications.   Therefore, it is less likely as not for the hypertension to have been aggravated beyond normal progression due to the medications for PTSD.  The examiner also considered and outlined all of the medical literature referenced and submitted in support of the Veteran's claim.  The examiner noted that the Veteran was diagnosed with hypertension in September 2002  and he was not on any psychiatric medications for PTSD at the time and as noted above, had no increase specific visits for uncontrolled hypertension related to the medication and although it is noted that there may be an increased risk of hypertension in persons with PTSD and depression, along with other risk factors,  which include age, obesity, family history, race, high sodium diet, excessive alcohol consumption, physical inactivity, the presence of other cardiovascular risk factors, and personality traits and depression, there is no actual cause and effect for PTSD to cause or aggravate hypertension.  The examiner found that the weight of the medical evidence is against a cause and effect for hypertension to be due to or caused by PTSD, although there may be a higher incidence, it does not cause the hypertension.  Further studies are needed to conclude that hypertension is caused by PTSD.  Therefore, it is less likely as not for the hypertension to be due to or caused by or aggravated by the service-connected PTSD with depression, and less likely as    not caused by or aggravated by the medication for prescribed for the same.

The Board has also reviewed the Veteran's post-service treatment records, but these records do not address whether the Veteran's hypertension was secondary to his PTSD.  

Based on the evidence of record, the Board finds that service connection for hypertension is not warranted.  In this regard, the highly probative September 2017 VA examiner determined that the Veteran's hypertension was not proximately due to, caused by, or aggravated beyond its natural progression by his service-connected PTSD with depression.  The examiner also offered a detailed rationale for such opinion.  The examiner specifically addressed the medical literature of record as well as the Veteran's medications.  No other medical opinion of record refutes the examiner's opinion.  

With respect to the medical articles submitted indicating an association between hypertension and PTSD, the Board notes that when medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion, a claimant may use such evidence to meet the requirement for a medical nexus.  Wallin v. West, 11 Vet. App. 509 (1998).  However, an attempt to establish a medical nexus between service and a disease or injury solely by generic information in a medical journal or treatise "is too general and inclusive."  Sacks v. West, 11 Vet. App. 314, 317 (1998) (a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element).  Still, medical treatise evidence can provide important support when combined with an opinion of a medical professional.  Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor's statements was "adequate to meet the threshold test of plausibility"). 

However, the September 2017 VA examiner considered the entire claims file, including the medical articles, when forming her opinion concerning the Veteran's hypertension and still found no such link between his hypertension and his service-connected PTSD.  Moreover, given that the articles are general in nature and do not specifically address the Veteran's disability, they have minimal probative value when weighed against the VA examination that is specific to the Veteran's case.  In this regard, the examiner thoroughly considered the Veteran's record and medical history when forming her opinion.  

The Board has also considered the Veteran's statements that he believes his hypertension is due to his service-connected PTSD with depression.  However, given that the Veteran does not have any special medical expertise, the Board must find that he is not competent to give a medical opinion on this issue.  See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions).  As such, the opinion of the VA examiner, a medical professional, is more probative than the Veteran's lay statements.  Thus, his statements are outweighed by highly probative VA opinion.

In conclusion, based on the analysis above, a preponderance of the evidence is against the Veteran's claim for service connection for hypertension.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply.  See 38 U.S.C.A. § 5107(b).


ORDER

Service connection for hypertension as secondary to service-connected PTSD with depression is denied. 




____________________________________________
R. FEINBERG
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs