Citation Nr: 21062026 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 16-18 574 DATE: October 6, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's acquired psychiatric disorder began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the Army from May 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claim was previously remanded by the Board in a November 2018 decision. Most recently, the claim was remanded by the Board in a March 2021 decision. The Board specifically directed the RO to obtain a VA addendum opinion as to whether the Veteran's mental health diagnoses are related to his active service, specifically his in-service psychiatric hospitalization. Addendum VA medical opinions were obtained in April and May 2021. Accordingly, the Board finds that the RO has substantially complied with the March 2021 Board remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for an acquired psychiatric disorder The Veteran contends that he has an acquired psychiatric disorder that is related to his active military service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110, 1131; 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 (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C. § 1112; 38 C.F.R. § 3.304. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, for Veterans who served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including psychosis, 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. §§ 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). 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). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition to the regulations discussed above, service connection for posttraumatic stress disorder (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 in-service stressor occurred. 38 C.F.R. § 3.304 (f). 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 the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (f)(2). 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. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service treatment records include his March 1969 induction examination that is negative for any mental health conditions or diagnoses prior to entering the service. During service, the service treatment records include a December 1970 note where the Veteran complained that the people next door are making so much noise, that he cannot sleep. He stated that he was becoming somewhat paranoid. The examining official noted that the Veteran should not be given sleeping pills. Shortly thereafter, in December 1970, the Veteran started experiencing delusions, auditory hallucinations, and sleeplessness. He was admitted to the psychiatric ward of a hospital for six days to rule out psychosis. During his hospital stay, the Veteran admitted to his problems started two weeks prior and he was using illicit drugs including marijuana, speed, LSD, hashish, and acid. The Veteran was diagnosed with acute brain syndrome, associated with probable drug toxicity. He was treated with phenothiazine therapy and all ideas of reference and vague hallucinatory experiences disappeared. The Veteran became asymptomatic and was discharged back to duty. There were no further reports related to the Veteran's drug use or psychiatric treatment. The Veteran's February 1971 separation examination does not include any notations for psychiatric diagnoses and defects, and his psychiatric disposition was checked as "normal." The Veteran's VA treatment records include an August 1997 internal medicine note completed by Dr. R.L., a staff physician. Dr. R.L. assessed the Veteran with PTSD after the Veteran complained of nightmares and flashbacks. He was referred to a PTSD group evaluation. In May 1998, the Veteran reported irritability, lethargy, chronic negative mood, and dysthymia during an urgent care appointment. The Veteran's previous diagnosis of PTSD from military service was noted. He was discharged from urgent care with diagnoses of depression and anxiety by Dr. A.S., and prescribed Paxil. He was referred to mental health. In November 2006, the Veteran visited with Dr. N.G., a staff physician with internal medicine. He stated that he is under a great deal of stress and may be depressed. He was diagnosed with probable depression, prescribed Citalopram, and referred to mental health. The Veteran's VA treatment records indicate that he did not complete a mental health evaluation until November 2009 with Dr. J.W., a staff psychologist. During the evaluation, the Veteran contended that his head does not feel right, and it is probably stress, as he has bills and is getting older. He stated that his anxiety started in September or October of 2009. He stated that he underwent individual counseling approximately 10 years ago for depression. Dr. J.W. diagnosed the Veteran with adjustment disorder, not otherwise specified (NOS). The Veteran's most recent mental health comprehensive assessment include in his VA treatment records occurred in March 2016 with licensed clinical social worker, T.G. The Veteran noted stress in his life, and reported having nightmares and abusing alcohol in past. He also noted his history in military of hospitalization for detox. He was diagnosed with depressive disorder, rule out dysthymia and alcohol use disorder, in remission. A subsequent mental health treatment note in March 2016 amended the Veteran's diagnosis to adjustment disorder with depressed mood and alcohol dependence, moderate to severe, in remission under the DSM-V criteria. T.G. opined that the Veteran did not meet the criteria for either PTSD or paranoid schizophrenia. The Veteran was first afforded a VA examination in October 2019. The examination was completed by a psychologist, Dr. M.G. who diagnosed the Veteran with adjustment disorder with depressed mood. In the examination report, Dr. M.G. referenced the Veteran's December 1970 psychiatric treatment and diagnosis of acute brain syndrome associated with probable drug use. During the examination, the Veteran related his stress to the loss of his wife's companionship, family issues, financial issues, and aging. He endorsed depressed mood. The Veteran stated his use of drugs in service as his in-service stressor; however, the examiner opined that this did not meet Criterion A for the purposes of a PTSD diagnosis under DSM-V. After examining the Veteran and reviewing the Veteran's claims file, Dr. M.G. opined that the Veteran does not meet the diagnostic criteria for PTSD. He found that the Veteran's currently diagnosed adjustment disorder is mild and arises from situational stress. Dr. M.G. noted that there are no further residual symptoms of drug use reported in service, and it is less likely than not that the Veteran's adjustment disorder is related to his verified in-service stressor. Pursuant to the March 2021 Board remand, an addendum VA medical opinion was completed in April 2021. Dr. M.G. reiterated that the Veteran does not have a diagnosis of PTSD and his adjustment disorder with anxiety and depressed mood is mild and appears to arise from situational stresses including the loss of his wife, family issues, financial issues, and aging. The examiner again noted that there were no further residual symptoms of drug use reported in service. His current VA treatment records do not note any current mental health complaints or treatment. Thus, it is less likely than not that the Veteran's current psychiatric disorder was incurred in or aggravated by his military service. Dr. M.G. provided an additional addendum opinion in May 2021 where he clarified that there are no current mental health complaints in the Veteran's VA treatment records. He also referred to the Veteran's in-service diagnosis of acute brain syndrome associated with probable drug toxicity and opined that the condition appeared to have resolved as there were no residual symptoms of drug use reported in service. The examiner again opined that it is less likely than not that any current psychiatric disorder was incurred in or aggravated by the Veteran's military service. After careful consideration of the evidence, the Board finds that the preponderance of the evidence is against finding that the Veteran's currently diagnosed acquired psychiatric disorder is at least as likely as not related to his service. As an initial matter, the Board finds that the Veteran does not have a diagnosis of PTSD that meets the requirements of 38 C.F.R. § 4.125 (a). 38 C.F.R. § 3.304 (f). The October 2019 VA examiner, Dr. M.G., opined that the Veteran's reported stressor of drug use in the military did not meet Criterion A of the DSM-V criteria for a PTSD diagnosis. Furthermore, Dr. M.G. found that the Veteran did not meet any of the criteria for a PTSD diagnosis under DSM-V. Additionally, in March 2016, T.G. opined that the Veteran did not meet the criteria for a PTSD diagnosis. Although Dr. R.L. assessed the Veteran as having PTSD in August 1997 due to his nightmares and flashbacks, the Board affords minimal probative value to this diagnosis. First, there is no evidence to support a finding that the diagnosis is supported by an examination report or supported by the criteria of DSM-IV or DSM-V. 38 C.F.R. § 4.125 (a); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). Second, the diagnosis was rendered by a staff physician rather than a psychologist or psychiatrist. Third, the diagnosis appears to be based solely on the Veteran's report of nightmares and flashbacks rather than a thorough review of the Veteran's claims file coupled with the Veteran's statements. See Reonal v. Brown, 5 Vet. App. 458 (noting medical evidence is inadequate where medical opinions are general conclusions based on the history furnished by the appellant and on unsupported clinical evidence). Consequently, the Board finds that the October 2019 VA examination finding that the Veteran does not have a diagnosis of PTSD offers significant probative value. The Board has also considered the May 1998 diagnoses of depression and anxiety and the November 2006 diagnosis of probable depression. But similar to the analysis above for PTSD, the Board finds that these diagnoses are not competent as the evidence does not support a finding that these diagnoses are based on a thorough evaluation or conform to DSM-IV or DSM-V criteria. 38 C.F.R. § 4.125 (a). The Board finds that the preponderance of the evidence shows that the Veteran has a diagnosis of adjustment disorder that is less likely than not related to his active military service. The November 2009 mental health evaluation, the March 2016 mental health assessment, and the October 2019 VA examination along with the April 2021 and May 2021 VA addendums all found that the Veteran had a diagnosis of adjustment disorder related to stress, including relationships issues, financial issues, and aging. The Board notes that the March 2016 and October 2019 evaluations conformed to the requirements of DSM-V and the November 2009 and October 2019 evaluations were completed by psychologists. The October 2019, April 2021, and May 2021 VA examiner opined that the Veteran's adjustment disorder was less likely than not related to his military service, including his in-service drug use. Furthermore, the October 2019 VA examiner opined that the Veteran's in-service diagnosis of acute brain disorder associated with probable drug toxicity resolved as there were no further reports in service regarding drug use or psychiatric treatment. The Board highlights the fact that the February 1971 separation examination was negative for any psychiatric diagnoses or defects. The Board finds that the totality of the October 2019 VA examination and the April 2021 and May 2021 addendum opinions are adequate and highly probative as they are based on an accurate medical history and provide explanations that contain clear conclusions with supporting data. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Also, as previously noted, Dr. M.G.'s findings are supported by the Veteran's November 2009 and March 2016 mental health evaluations. The Board acknowledges the Veteran's belief that he has a psychiatric condition related to his active service. As a lay person, however, the Veteran has not shown that he has specialized training sufficient to render such an opinion or diagnosis. 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). Consequently, the Board gives more probative weight to the competent medical evidence which determined that the Veteran's diagnosed condition is less likely than not related to his active service. Accordingly, entitlement to service connection for an acquired psychiatric condition is denied. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine does not apply. Gilbert, 1 Vet. App. at 54; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hartford, 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.