Citation Nr: 21063377 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 18-00 285A DATE: October 14, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for an acquired psychiatric disability is denied. FINDINGS OF FACT 1. The Veteran does not have a PTSD diagnosis under the criteria set forth in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders 2. The Veteran's claimed acquired psychiatric disability did not manifest during service and is not otherwise related to service. CONCLUSIONS OF LAW 1. PTSD was not incurred in service and is not attributable to service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304(f). 2. An acquired psychiatric disability was not incurred in service and is not attributable to service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304(f). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1980 to December 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a travel Board hearing. A copy of the transcript has been associated with the Veteran's electronic claims folder. Service Connection Entitlement to service connection for an acquired psychiatric disability, to include PTSD The Veteran contends that she is entitled to service connection for an acquired psychiatric disability, to include PTSD, because she experienced military sexual trauma while in service. See September 2016 VA Form 21-0781a; Board Hearing Transcript, p 6, 15-16. For the reasons explained below, the Board finds that entitlement to service connection for an acquired psychiatric disability, including PTSD, is not warranted. In order to obtain service connection under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303 (a) a Veteran must satisfy 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 or aggravated during service - the so- called 'nexus' requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). The Board acknowledges that VA, effective March 19, 2015, amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the Court of Appeals for Veterans Claims (CAVC), or the United States Court of Appeals for the Federal Circuit. As the Veteran's claim was certified to the Board in December 2018 (after August 4, 2014), the diagnosis of his PTSD should conform to DSM-5. See 38 C.F.R. § 4.125 (a). Service treatment records indicate conflicting evidence about a suspected suicide attempt in January 1982. Personnel records indicate in a July 1986 report that the Veteran's top security clearance was revoked after testing positive for cocaine. A November 2016 VA treatment record indicates that the Veteran reported a troubled history with her mother, including alleged childhood abuse and homicidal thoughts towards her mother. A December 2016 VA treatment record indicates that Dr. E.M. diagnosed the Veteran with PTSD, mood disorder, unspecified, and bipolar type II and a history of reported childhood abuse and military sexual trauma. The Veteran was afforded a VA examination in January 2017 where the examiner opined that the Veteran did not have a mental disorder which met the DSM-5 criteria for PTSD. The examiner further opined that although the Veteran met the criteria for a mental condition, it was not related to service. The examiner reasoned that there were other stressors which predated her alleged in-service stressor as well as other non-service-related factors which likely caused the mental disorder. The Veteran reported a relatively uneventful history post-service until she underwent regression therapy, and it was revealed that she experienced military sexual trauma. Since the regression therapy, she has been in a downward spiral. Since the examiner did not specifically address favorable evidence, including Dr. E.M.'s PTSD diagnosis, the Board remanded the matter to obtain an addendum medical opinion. An October 2018 statement from Reverend H.J. indicates that the Veteran suffers from PTSD secondary to military sexual trauma. Reverend H.J. stated that she began regression therapy with the Veteran and that while under hypnosis, the Veteran was fighting, crying and yelling, "Get off me." Reverend H.J. also stated that the Veteran later shared that her mother and old friend told her that she once tried to kill herself after a sexual assault incident involving her superior during service. The Veteran told Reverend H.J. that the regression therapy awakened negative feelings. In an April 2019 letter, Dr. M.G. opined that it was more likely than not that the Veteran suffers from PTSD that is related to service. Dr. M.G. indicated that the Veteran experiences symptoms that meet the criteria for PTSD, generalized anxiety disorder and insomnia due to other mental conditions. In a March 2020 addendum opinion, a VA psychiatrist opined that the Veteran's only diagnosis was mental disorder, unspecified. The psychiatrist opined that it was less likely that any of the Veteran's claimed mental diagnoses were related to service. The psychiatrist explained that although a PTSD diagnosis was noted in some clinical records, the diagnosis was not supported by any testing or clear delineation of symptoms to meet the criteria for PTSD. The psychiatrist addressed potentially favorable evidence which indicated multiple diagnoses and explained that while she could not account for why other clinicians provided these diagnoses or opinions, the Veteran's records and current state did not support any current mental disorder that is related to service. She further noted that it was unclear if Dr. M.G. had the benefit of the Veteran's electronic claims folder before providing his conclusion. The Board finds that the March 2020 VA medical opinion is the most probative evidence of record. It was based upon a thorough review of the record and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion.") The clinician addressed favorable evidence and distinguished her opinion from other evidence of record. She provided a well-reasoned rationale for all opinions reached. She concluded that the Veteran did not meet the criteria for a PTSD diagnosis and although the Veteran suffered from a mental disorder, it was not related to service. The Board does not assign probative value to Dr. E.M.'s diagnosis of PTSD as it lacks the requisite symptoms to support such a diagnosis. Further, the Board does not assign probative value to Dr. M.G.'s April 2019 statement. As the March 2020 clinician noted, Dr. M.G. does not indicate whether he reviewed the Veteran's electronic claims folder. While not in and of itself fatal to a medical opinion, see Nieves-Rodriguez v. Peake, 22 Vet. App. 296 (2008), the Board observes it is significant in the instant case. A full review of the clinical history would have disclosed that the Veteran's clinical history does not fully support a PTSD diagnosis. The Board affords more weight to the report of the March 2020 examiner. The Board likewise assigns minimal probative value to Reverend H.J.'s characterization of the Veteran's symptoms as meeting the requirements for a diagnosis of PTSD related to military sexual trauma. There is no evidence that Reverend has the requisite knowledge to make such a medical diagnosis. The Board does not assign probative value to the VA treatment records which indicate a diagnosis of PTSD for the reasons enumerated by the March 2020 clinician. Although the word PTSD has been used in various VA treatment records, there is evidence that it was used as a means to note the Veteran's subjective mental health history. There is no evidence that a thorough review of the Veteran's symptoms met the PTSD criteria as required by VA regulations. Additionally, the Board acknowledges the Veteran's assertions that she suffers from PTSD. While the Veteran can competently report psychiatric symptoms, any opinion regarding whether those symptoms meet the DSM-5 criteria for a diagnosis of PTSD requires medical expertise under VA's regulation. As such, the Board assigns no probative weight to the lay assertions that the Veteran currently suffers from PTSD. Accordingly, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for an acquired psychiatric disability, to include PTSD. The "benefit-of-the-doubt" is not applicable, as there is not an approximate balance of evidence. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Baskerville 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.