Citation Nr: 20044908 Decision Date: 07/06/20 Archive Date: 07/06/20 DOCKET NO. 16-53 353A DATE: July 6, 2020 ORDER An initial rating in excess of 70 percent for other specified trauma and stressor-related disorder is denied. Service connection for a right ankle disorder is denied. Service connection for a left leg disorder is denied. Service connection for a back disorder is denied. FINDINGS OF FACT 1. The Veteran served on active duty from January 2003 to February 2004 and from July 2007 to June 2008; he has been 100 percent disabled based on unemployability since May 2016. 2. An acquired psychiatric disorder has been manifested by subjective complaints of anxiety, depression, hypervigilance, and trouble sleeping; objective findings include casual dress and appropriate grooming, constricted but congruent affect, unimpaired speech and thought processes, anxiety, hypervigilance, good judgment and insight, impaired impulse control, and difficulty establishing and maintaining effective work and social relationships and adapting to stressful circumstances. 3. A right ankle disorder has not been shown. 4. Left leg pain was shown in service, but symptoms were not shown to be chronic; a current left knee disorder, diagnosed as left knee strain, is not causally or etiologically related to service. 5. A back disorder was not shown in service and is not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 70 percent for other specified trauma and stressor-related disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (DC) 9411 (2019). 2. A right ankle disorder was not incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2019). 3. A left leg disorder was not incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2019). 4. A back disorder was not incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating for Psychiatric Disability Disability ratings are determined by the applications of the VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. All psychiatric disabilities are evaluated under a General Rating Formula for Mental Disorders (“General Rating Formula”). Under DC 9411 and the General Rating Formula for Mental Disorders, a 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation for a psychiatric disability is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Initially, the Veteran was diagnosed with PTSD, other specified trauma and stressor related disorder, and bipolar disorder, and service connection has been granted for other specified trauma and stressor-related disorder. As there is no indication that any medical provider has distinguished between the specific symptoms of each of his different mental health disorders, all symptoms will be discussed. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Turning to the evidence, in February 2014, a VA examiner indicated the Veteran’s symptoms did not meet the diagnostic criteria for posttraumatic stress disorder (PTSD) under DSM-5 criteria; rather, he diagnosed with other specified trauma and stressor related disorder. The examiner indicated the Veteran experienced psychiatric symptoms of avoidance, irritability, hypervigilance, sleep disturbances, chronic sleep impairment and suspiciousness. He observed that the Veteran had good hygiene, memory and communication, as well no suicidal ideations or intentions. In an August 2016 private medical opinion, the clinician found that the Veteran’s other specified trauma and stressor related disorder signs or symptoms resulted in occupational and social impairment with deficiencies in most areas. The examiner documented depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss and flattened affect. The clinician further reported that the Veteran had symptoms of difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, suicidal ideation, impaired impulse control, persistent delusions or hallucinations and persistent danger of hurting himself or others. The examiner noted the Veteran had “great ongoing difficulty with his symptom pattern” and he reported that he could “no longer enjoy the simplest of activities.” The examiner further indicated the Veteran’s psychiatric disability caused him to miss work three or more times per month, as well as causing him difficulty concentrating and irritability. In a June 2019 VA examination, the Veteran reported that he was living with his wife of 13 years and his son. He endorsed not trusting anyone besides his wife and son, and he considered his wife to be his caretaker. He denied conflicts or arguments in his marriage. He reported his relationship with his son to be pretty good, and he described his son as a great kid. He related that his daily activities included projects around the house such as making wooden flags and expanding his deck, conducting security checks outside around his property, taking care of his two dogs and cat, and helping his son with homework. The examiner diagnosed PTSD and bipolar disorder. The examiner documented symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner stated that PTSD and bipolar disorder signs or symptoms resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner observed the Veteran to be casually dressed, with good hygiene, and he was alert and oriented to all spheres. His mood over the past two weeks was “really, really down and dark, like to the point where [he] couldn’t move,” but he indicated that “this is my third day I’ve been in the up.” Speech was within normal limits in articulation, rate, tone, volume, and production. The Veteran’s memory abilities (e.g. immediate, recent, and remote) were intact, as indicated by his performance throughout the interview. His memory functioning was not formally assessed. His thought processes were logical and organized. There was no evidence of delusional thought content (i.e. inaccurate yet fixed beliefs) or perceptual disturbances (e.g. auditory or visual hallucinations). A review of the VA treatment records suggests psychiatric symptoms consistent with many of those noted in the August 2016 and June 2019 medical opinion. VA treatment records in 2016 support that the Veteran was experiencing suicidal ideation, including records from November and December 2016. A January 2017 VA treatment record shows that he had a suicidal ideation and attempted suicide. However, he was unable to locate the gun and his “thought dissipated shortly, and his mood improved after disclosing the loss of his job to his wife. An April 2017 VA treatment record noted that the Veteran had a previous suicide intention in December 2016, when he believed he was being fired from his job. He reported the suicidal thoughts built for two days and ended with him being unable to access a gun. The examiner indicated his mood improved thereafter, however, he still reported passive suicidal ideation, including that his family may be better off without him. The examiner stated the Veteran had a history of suicide attempts and was at a chronically elevated risk of harm to self. A September 2017 VA treatment record shows that the Veteran related that he was doing alright and he was not having the more significant highs and lows that characterized his bipolar disorder prior to initiation of mood stabilizing medication. He indicated that his PTSD symptoms remained an issue and he managed them by controlling his environment by not going out much and staying within the protective circle of his family. The Veteran reported that he attended his son’s football games but that he felt very anxious and hypergiant at the games. The clinician observed that the Veteran was neat, well-groomed, and alert and oriented to all spheres. His mood was okay, affect congruent and situation appropriate, thoughts linear logical and goal oriented and no evidence of delusions, paranoia, suicidal or homicidal ideations. A February 2018 VA treatment record shows that the Veteran reported a period several weeks previously of forgetting to take his medication. The clinician observed that the Veteran was neat, well groomed, calm, cooperative, and oriented to all spheres. His mood was jittery, affect congruent and situation appropriate, his speech was normal and his thought process was linear, logical, and goal oriented. The clinician found no evidence of delusions, paranoia, suicidal or homicidal ideations. An August 2018 VA treatment record shows that the Veteran reported that he was doing about the same. He indicated depressed periods and on his darkest days he did not get out of bed and sometimes thought of suicide. The clinician observed that the Veteran was neat, well groomed, calm, cooperative, and oriented to all spheres. The Veteran’s mood was frustrated, affect congruent and situation appropriate, his speech was normal and his thought process was linear, logical, and goal oriented. The clinician found no evidence of delusions, paranoia, or homicidal ideations and found chronic intermittent suicidal ideations without plan or recent intent. After considering the totality of the record, the medical weighs against a rating in excess of 70 percent for the entire period on appeal. Significantly, the Veteran’s psychiatric disability does not result in total occupational and social impairment, for which the next higher rating of 100 percent would be warranted. Further, the symptomatology does not include gross impairment in thought processes or communication. As noted, the Veteran has exhibited normal thought processes and judgment and was able to converse in a normal, logical manner. Further, he has not reported persistent delusions or hallucinations and has displayed no detachment from reality. The Veteran’s behavior has not been grossly inappropriate and he has not been a persistent danger to himself or others. He continued to pay attention to hygiene and self-care and had good relationships with his wife and son. Additionally, although there were complaints of suicidal ideation and a reported suicide attempt in 2016 after the loss of his job, at no point did the Veteran show that he was persistent danger of hurting himself or others. Thus, his symptomatology does not support a rating in excess of 70 percent. The Board has considered the Veteran’s lay statements that his disability is worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s acquired psychiatric disorder has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable, and a rating in excess of 70 percent throughout the appeal period is denied. Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303 (a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Right Ankle As to first element of service connection – a current disorder – the record includes significant evidence of the Veteran’s medical history, to include VA and private treatment records and VA examinations; however, these records are silent for diagnoses of chronic disabilities or treatment for a right ankle disorder. The STRs show an August 2003 record indicated moderate right ankle swelling seen laterally, some irregularity of the bone outline at the proximal dorsal aspects of the tarsonavicular bone, found as probably related to a healed chip fracture. A December 2003 Report of Medical History for separation noted a left ankle stress fracture, resolved with no sequel currently, with normal physical examination and normal imaging. In a June 2019 VA examination, no diagnosis was rendered with respect to his right ankle. VA and private treatment records were also reviewed and are silent as to right ankle disorder or symptomatology reasonably attributable thereto. As such, the medical evidence does not support a finding of current disorder related to the right ankle. The Veteran is competent to report symptoms as they come to him through his senses; however, a musculoskeletal ankle disorder is not the type of disorder that a lay person can provide competent evidence on or answer questions of etiology or diagnosis. Such competent evidence has been provided by the medical personnel who have treated the Veteran during the current appeal and by service and medical records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. Service connection may not be granted for a diagnosis of a disability by history. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Accordingly, as no current disorder is shown with respect to a right ankle disorder, the appeal is denied.  Left Leg Turning to the medical evidence, a June 2019 VA examiner diagnosed left knee strain. As such, a current disorder is shown and the first element of service connection is met. As to in-service incurrence, STRs reflect a July 2003 complainant of left knee pain, including sharp pain after running and dull pain while walking. The Veteran noted that squatting caused him discomfort. A December 2003 service record indicated that he reported feeling sick due to medication he was taking at the time and his left leg was numb. Therefore, the second element of service connection is met. As to nexus, the medical evidence does not support a nexus between a left leg disorder and service. In June 2019, a VA examiner opined that that it was less likely than not that the left leg disorder was caused by or a result of service. The examiner noted that the Veteran reported that he was playing softball while on active duty in 2003 and he fell and injured his knee; however, the examiner reasoned that the Veteran separated from his first period of service in 2004 and there were subsequent records of treatment for a left knee disorder, he was then deployed from 2007-2008 with no records of limitations or frequent visits for any left knee complaints. The examiner explained that after leaving the military in 2008, there were no records of concern for a left knee disorder within the next five years. This evidence weighs against a nexus. Thus, the medical evidence does not support a nexus between service and a left leg disorder and the third element of direct service connection is not met. Back Disorder Turning to the medical evidence, a June 2019 VA examiner indicated that the Veteran has been diagnosed with degenerative disc disease (DDD) of the lumbar spine since 2016. As such, the first element of service connection is met. As to in-service incurrence, the STRs are silent for complaints, treatment, or diagnoses of a back disorder. Accordingly, an in-service incurrence has not been established, the second element of service connection has not been met, and the medical evidence does not support service connection on a direct basis. To the extent that the Veteran asserts a nexus between his back disorder and service, the evidence does not support a nexus. In June 2019, a VA examiner opined that it was less likely than not that the Veteran’s back disorder was caused by or a result of service. The examiner reasoned that the Veteran’s STRs did not support a significant injury or frequent visits for low back pain that would be the result of his now-mild DDD of the lumbar spine. Thus, he concluded that the progression of aging was a more likely cause of DDD of the lumbar spine. In sum, the evidence does not show that the Veteran experienced a back disorder or establishes a medical nexus between service and a back disorder. In light of the above, the medical evidence weighs against the claim of service connection for a back disorder. The Board has considered the Veteran’s lay statements that his disorders were caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorders due to the medical complexity of the matters involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claims for service connection and there is no doubt to be otherwise resolved. As such, the appeals are denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not   required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Grzeczkowicz The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.