Citation Nr: 21000506 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-44 917 DATE: January 5, 2021 ORDER Service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder (MDD), and mood disorder is denied. FINDING OF FACT The weight of the evidence is against a finding that any current acquired psychiatric disorder manifested during, or as a result of, the Veteran’s active duty service; and, there is no credible supporting evidence to corroborate the Veteran’s claimed in-service stressors. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, MDD, and mood disorder are not met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 2010 to October 2011. This case is before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for PTSD and MDD. The Veteran’s notice of disagreement (NOD) was received in February 2014. The RO issued a statement of the case (SOC) in October 2015. The Veteran’s VA Form 9, substantive appeal to the Board, was received in December 2015 at which time the Veteran requested a hearing. In December 2018, the Veteran was notified, at his most recent address of record, that his hearing before the Board was scheduled for February 2019. The Veteran failed to appear for the hearing, however, and has yet to provide a good-cause explanation for his absence or requested to reschedule the hearing. As such, the hearing request is considered withdrawn. 38 C.F.R. § 20.704(d). Although previously represented by a private attorney in this appeal, the attorney has withdrawn her representation of the Veteran as confirmed in an August 2018 letter from the Board to her. This matter was previously before the Board in December 2019 at which time it was remanded for further development and adjudicative action. It has now returned to the Board. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology for specific chronic disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, such as arthritis and psychoses, may also be established based upon a legal “presumption” by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Psychoses include brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified (NOS), other specified schizophrenia spectrum or other psychotic disorder, schizoaffective disorder, schizophrenia, schizophreniform disorder, and substance-induced psychotic disorder; but not PTSD, depressive, anxiety, or panic disorders. 38 C.F.R. § 3.384. A claim for service connection for a psychiatric disability is deemed to encompass all psychiatric diagnoses reasonably presented in the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, MDD, and mood disorder is denied The Veteran contends that his acquired psychiatric disorder, to include PTSD, MDD, and mood disorder are related to active service. The Veteran relates his PTSD to two claimed in-service stressors, specifically, two different incidents in which he witnessed the suicide of a fellow soldier. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. In addition to the general service connection requirements stated above, establishing service connection for PTSD, as opposed to other mental health disorders, requires the following: (1) medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The Veteran’s Service Treatment Records (STRs) are silent as to any psychiatric disorder. The Veteran reports no history of mental illness in his June 2011 medical history. During the Veteran’s exit exam in August 2011, the doctor noted, “Axis I (psychiatric conditions) Cocaine abuse” and negative results for a PTSD screening. Medical records, after service, show the Veteran has a diagnosis of PTSD, depression and mood disorder in August 2012. (See August 2012 Private Clinic Note; September 2012 VA Psychiatry Note; September 2012 Psychiatry Consult) During a September 5, 2012 VA Psychiatry consult, the doctor diagnosed the veteran with depression and PTSD by way of history. A private clinician record noted the Veteran was seen for “anxiety related to PTSD with aggressive notations with concerns of bipolar disorder” but does not formally diagnose the Veteran with bipolar disorder. Furthermore, there is no evidence of a PTSD diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria. (See August 2012 Private Clinic Note; September 2012 VA Psychiatry Note; September 2012 Psychiatry Consult). Even if the record showed a PTSD diagnosis based on the DSM criteria, the Veteran’s alleged stressors have not been independently corroborated. When a reported stressor is not related to either combat or the fear of hostile military or terrorist activity, then a Veteran’s statements and testimony alone are not enough to establish the occurrence of a claimed in-service stressor. Hall v. Shinseki, 717 F.3d 1369 (2013). There must be credible supporting evidence that the in-service stressor happened. Cohen v. Brown, 10 Vet. App. 128, 138 (1997). In this case, the evidence does not show that the Veteran engaged in combat, or that he was exposed to hostile military or terrorist activity; therefore, the presumptions afforded to veterans who allege fear of hostile military or terrorist activity are inapplicable in this case. (See DD-214) Hence, any alleged in-service stressors must be independently verified, i.e., corroborated by objective, credible supporting evidence. Claimed Stressor A On September 5, 2011, the Veteran anonymously posted a journal entry to the VA PTSD website titled “I Lost Friends To Suicide.” In the post he states that he is four weeks out of the Army, discharged for failing a drug test. The Veteran goes on to share that he returned to his barracks and found that his roommate had hung himself. The Veteran said he attempted to revive his roommate but was unsuccessful and reported to battalion staff duty with the body. He explains that this event led to him “self-medicating.” (See September 2011 Correspondence; VA Form 21-0781) The VA has made multiple attempts to verify the alleged stressor, however, no evidence of the event was ever found. The Veteran was unable to provide the first name of his roommate but did provide a last name. A July 2013 formal finding notes that a Defense Personnel Records Information Retrieval System (DPRIS) response states, “[w]e researched the US Army casualty information available to this office. The casualty information did not document a [roommate] listed as a casualty in 2011 at Fort Benning, Georgia due to self-inflicted wound.” In addition to the DPRIS response, a full review of the Veteran’s personnel records was conducted. Consequently, VA issued a formal finding that it cannot corroborate the Veteran’s stressor statement. (See June 2013 VA Form 21-301; September 2015 VA Memo) In September 2015, VA issued an addendum to the July 2013 formal finding indicating that, after further development, including requests for crime records of the stated in-service stressor, VA received a response of “no record.” Thus, VA again issued a formal finding noting the Veteran’s stated in-service stressor is not verified. Therefore, the Veteran’s claimed stressor A has not been corroborated. Claimed Stressor B Evidence in the file cites another possible in-service stressor as an additional basis of the Veteran’s claim for service connection for PTSD. As discussed above, the Veteran’s first mention of an additional stressor comes as one line at the end of a detailed entry regarding his roommate’s alleged suicide. The Veteran states, “Following all of this I’ve lost another due to self-execution.” (See September 2011 Correspondence; VA Form 21-0781) The Veteran furnishes no further details regarding the second alleged stressor until he is admitted to a VA hospital for treatment. In a September 6, 2012 Psychiatric Outpatient Note, the doctor states, “the Veteran having witnessed two fellow soldiers in basic [training] shot themselves and also he had found his roommate hung.” At the time of the rating decision, no efforts had been made to verify this event. However, on remand, the Board directed the RO to attempt verification of this additionally-claimed stressor and, if verified, to have the Veteran undergo a VA examination to determine whether he has PTSD. Notwithstanding returned mail from the Veteran’s last known address, dated December 29, 2016, upon remand the RO made several attempts to contact the Veteran to obtain any additional information to assist in verifying the second alleged in-service stressor: witnessing a fellow servicemember committing suicide by gunshot wound on the firing range at Fort Benning sometime between October 2010 and October 2011. The RO sent subsequent development letters in January 2020, February 2020, and March 2020. The RO letters afforded the Veteran the opportunity to supplement his claim with any additional evidence such as lay evidence from people who had observed the event or the subsequent changes in the Veteran’s personality or demeanor. No response was ever received. The Veteran has a duty to keep VA apprised of his current address. Jones v. West, 12 Vet. App. 98 (1998). VA is not required to “turn up heaven and earth to find him.” Hyson v. Brown, 5 Vet. App. 262, 265 (1993). “If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence.” Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA has the discretion to determine when additional information is needed to adjudicate a claim. The Veteran is expected to cooperate in the efforts to adjudicate his claim for service connection. His failure to do so subjects him to the risk of an adverse adjudication based on an incomplete and underdeveloped record. Kowalski v. Nicholson, 19 Vet. App. 171 180-181 (2005). Therefore, despite significant effort, VA has not been able to corroborate the Veteran’s claimed stressor B. Accordingly, service connection for PTSD is not warranted. With regard to the Veteran’s other claimed psychiatric disorders, the preponderance of the evidence is against finding that they had their onset during service, or are otherwise related to service. Much of the Veteran’s medical treatment and diagnoses are based on his version of events related to his time in active service. The Veteran contends that he witnessed his roommate’s hanging in his barracks, cut him down and took his lifeless body to military staff, and that just a few days later he witnessed two soldiers shoot themselves during basic training. (See September 2011 Correspondence; VA Form 21-078; September 2012 VA Psychiatric Outpatient Note). However, as noted below, the credibility of the Veteran’s statements are in doubt. In this case, the foundation for the medical diagnoses for any acquired psychiatric disorder having a relationship to the Veteran’s time in service is substantially premised upon the Veteran’s self-reported history. However, the evidence of record is filled with inconsistencies from the Veteran thereby calling his credibility into question. First, the Veteran’s website post, as previously discussed, mentions the Veteran reporting his roommate’s suicide to his battalion staff. It is reasonable to expect the base would have thoroughly documented such events for the sake of the soldiers’ families, for military records, and for any investigative purposes. However, the VA was never able to locate any record of the event, nor any record of the alleged roommate’s existence. (See September 2015 VA Memo) Moreover, within a week of the Veteran’s discharge, despite the single incident of drug use, the Veteran’s Staff Sergeant, wrote him a glowing recommendation letter noting the Veteran’s awards and achievements during service. The letter makes no mention of any hardships faced by the Veteran, including the witnessing of any suicides, nor any changes seen in the Veteran’s personality. It is reasonable to infer from such an omission that the Sergeant was unaware of such events. This appears wholly inconsistent under such circumstances in which such a grave event would not only be known to all parties present on the base but also thoroughly documented by leadership. (See October 2011 Recommendation Ltr.) Second, in the original post the Veteran describes having “pushed the only family I have away, and have nothing else.” However, the Veteran’s address of record has been that of his mother’s before and after service. By November 2011, according to notes in his medical records, the Veteran was living at home with his mother while engaged to his pregnant girlfriend. His mother taking him back into their home after discharge from service and having a relationship with his girlfriend is inconsistent with his pushing away the only family he has left. (See September 2011 Correspondence; October 2012 VA Discharge Summary) By August 31, 2012, within a year of his October 2011 discharge, medical records indicate the Veteran suffers his first suicide attempt. Within days comes a second attempt in which the Veteran describes both incidents as accidental, due to mixing his medication and alcohol. He is admitted to the intensive care unit for a 72 hour hold while his mother obtains a court order to have him involuntarily committed to a VA hospital. The Veteran is held from September 4, 2012 to September 7, 2012 at which point he is transferred to another VA facility and released September 11, 2012. Doctors speak to the Veteran’s mother throughout his treatment; at no point in time does she mention her son witnessing multiple suicides within days of each other while he was in the military. Given, that he is hospitalized for attempted suicide, it seems wholly unreasonable to conclude that she would have omitted such information about her son to his doctors. Upon release, the Veteran applies for VA disability. (See October 2012 VA Discharge Summary) Third, while hospitalized, the Veteran shares several different versions of his time in service including that he had been in the army for two years instead of one. He describes having been in combat drills and having witnessed the death of “buddies blown up” in addition to friends committing suicide during service. The Veteran also tells doctors that he graduated with his class and that only 30 of 50 of his classmates had survived their time in Afghanistan. As discussed above, the Veteran never saw combat and the suicides have never been verified by the VA. (See August 13, 2012 Progress Note; DD-214; October 2012 VA Discharge Summary; September 2015 VA Memo) Given the number of inconsistencies, from the Veteran’s recommendation letter failing to mention any suicides on base, to his mother’s continuous support, to the allegations of the length of time he was in service, to his graduating with his class, to what he alleges to have witnessed in service, to total lack of verification of the alleged stressors, the Board does not find the Veteran credible. The medical diagnoses of PTSD, MDD and any related mood disorder are based on the Veteran’s self-reported history, which as explained above is not credible. A medical opinion may not be disregarded solely on the rationale that it is based on a history given by the veteran, see Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2006); and that is not the case here. Rather, for the reasons indicated above, the other facts in record contradict the Veteran’s self-reported history of the facts that formed the basis of the opinion. Kowalski, 19 Vet. App. at 179 (citing Reonal v. Brown, 5 Vet. App. 458 (1993)). As explained above, the Board does not find the Veteran credible in recounting the history of suicides he alleges witnessing in service. For this reason, the August, September, and October 2012 medical opinion are not persuasive, given its reliance on a history that is not credible. (See August 2012 Private Clinic Note; September 2012 VA Psychiatry Note; September 2012 Psychiatry Consult; October 2012 VA Discharge Summary). Additionally, the Veteran does not have a psychosis diagnosis, and therefore, his psychiatric disorder may not be presumed to have been incurred during service, even though it was manifested within the first post-service year because it is not one of the listed chronic diseases under 38 C.F.R. § 3.309(a). Given the absence of evidence in support of the Veteran’s claim, due in large part to the Veteran’s lack of participation, for the Board to conclude that the Veteran’s asserted claim for an acquired psychiatric disorder was incurred during service would be speculation, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. at 33. In making this determination, the Board has weighed the STRs and medical evidence, including the VA medical opinions, against other evidence of record, including the Veteran’s contentions. In arriving at the decision to deny this claim, the applicability of the benefit-of-the-doubt doctrine has been considered. However, as the preponderance of the evidence is against this claim, that doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990) L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Ardalan, Associate Counsel 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.