Citation Nr: 21064111 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 15-42 835 DATE: October 19, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a recurrent multiple joint disability is denied. REMANDED Entitlement to a rating in excess of 30 percent prior to September 6, 2019, and in excess of 50 percent on and after September 6, 2019, for major depressive disorder is remanded. FINDINGS OF FACT 1. Service connection has been established for major depressive disorder. 2. PTSD has not been shown to have originated during active service. 3. A recurrent multiple joint disability was not manifested during active service or at any time thereafter. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for entitlement to service connection for a recurrent multiple joint disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 2000 to June 2004. He served in Iraq and was awarded the Combat Infantryman Badge. Service Connection Service connection may be granted for recurrent disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). PTSD The Veteran asserts that service connection for PTSD is warranted as the claimed disability was manifested as the result of his combat-traumatic experiences in Iraq, including the deaths of several service comrades. Service connection for PTSD is to be established where there is a current diagnosis of PTSD; credible supporting evidence that the claimed in- service stressor actually occurred; and evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. If the evidence establishes that a 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. 38 C.F.R. §§ 3.304(f), 4.125(a). The service treatment records reflect that the Veteran was seen for psychiatric complaints. A November 2003 hospital discharge summary from Cumberland Hall Hospital indicates that the Veteran was transferred from an Army hospital because "of recent concerns of danger to self." The Veteran was diagnosed with recurrent major depressive disorder and impulse control disorder. Service connection has been established for major depressive disorder, An October 6, 2009, Department of Veterans Affairs (VA) psychological evaluation states that the Veteran complained of PTSD symptoms including combat related nightmares; episodes in which he became non responsive; anger; irritability; and frustration. The Veteran was diagnosed with PTSD. An October 20, 2009, VA mental health clinic treatment record states that the Veteran was diagnosed with major depressive disorder. The VA psychologist concluded that the Veteran did not have "PTSD as a result of his military service." She clarified that: "a key hallmark of PTSD is avoidance, the Veteran stated during the SCID 'it makes me feel better to talk about it;'" "when the Veteran was asked about his traumatic experiences, he told them in detail to this provider with little to no emotional affect;" and "individuals with PTSD avoid talking about their traumatic events and when they do, little details are disclosed." A January 2010 VA treatment record states that the Veteran was diagnosed with PTSD and depression. The report of a July 2010 VA psychiatric examination states that the Veteran was diagnosed with a not otherwise specified anxiety. He was specifically found not to meet the criteria for a PTSD diagnosis. The report of a September 2010 VA psychiatric examination states that the Veteran was diagnosed with recurrent major depressive disorder and a not otherwise specified anxiety disorder. A February 2011 VA treatment record indicates that the Veteran was diagnosed with PTSD. The report of an August 2011 VA psychiatric examination states that the Veteran was diagnosed with recurrent major depressive disorder. The examiner commented that: "the Veteran does not describe the full spectrum of symptomatology that meets the criterion for the DSM IV diagnosis of PTSD;" "symptoms reported by the Veteran are most likely associated with the depression;" and "I agree with the opinion provided by a previous psychologist that he does not have PTSD." The report of a January 2013 psychiatric examination conducted for VA states that the Veteran was diagnosed with recurrent major depressive disorder. A June 2013 VA mental health clinic treatment record states that the Veteran was diagnosed with recurrent major depressive disorder and a "chronic adjustment disorder with anxiety and depression (post combat)." The report of a September 2019 psychiatric examination conducted for VA states that the Veteran was diagnosed with major depressive disorder. The examiner concluded that the "Veteran has a history of depression with anxiety since returning from Iraq" and "he has worked an infantryman and experienced much distress, and symptoms meet criteria for depression as opposed to PTSD." The Veteran asserts that service connection for PTSD is warranted secondary to his traumatic combat related experiences in Iraq. The service treatment record reflect that the Veteran was treated and hospitalized for a psychiatric disability diagnosed as major depressive disorder. Service connection has been established for that disability. While the record reflects that the Veteran has been diagnosed with PTSD on occasion, a preponderance of the in service and post service psychiatric evaluations have concluded that the Veteran's proper psychiatric disability is major depressive disorder, and he does not meet the diagnostic criteria for PTSD. The Veteran asserts that he has PTSD secondary to his combat experiences and the diagnosis of major depressive disorder is incorrect. No competent medical professional has concluded that major depressive disorder is an incorrect diagnosis of the service connected disability. The Veteran's claim is supported solely by his own statements on appeal. Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board finds that the Veteran's lay statements do not constitute competent evidence to establish that the service connected major depressive disorder should be recharacterized as PTSD and/or that the Veteran has PTSD. The Veteran has not offered any medical or other healthcare qualifications. The Veteran is not competent to diagnose PTSD or to offer an opinion regarding the relationship between PTSD and the in service psychiatric disability. The question of such a psychiatric diagnosis requires medical training and specific clinical testing and is too complex to be addressed by a layperson. VA has acknowledged that a recurrent psychiatric disability originated during active service; has established service connection for major depressive disorder; and assigned a compensable rating for the psychiatric disability. While the Veteran has asserted that the diagnosis of major depressive disorder is incorrect and should be recharacterized as PTSD, the preponderance of the competent evidence of record establishes that the Veteran does not meet the criteria for a PTSD diagnosis. The Board notes that the characterization of the service connected psychiatric disability does not affect the amount of disability compensation benefits awarded to the Veteran as both major depressive disorder and PTSD are to be rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Therefore, the Board concludes that service connection for PTSD is not warranted. Recurrent Multiple Joint Disorder The Veteran asserts that service connection for a chronic multiple joint disability is warranted. In his June 2011 claim for service connection, the Veteran clarified that "I request that the VA open a claim for disability compensation benefits for joint aches." He clarified that "I take a lot of over the counter pain medications like Tylenol to help with the achiness and stiffness." The reports of an October 2019 fibromyalgia examination and an October 2019 Gulf War examination conducted for VA states that the Veteran denied experiencing both "widespread muscular/joint pains" and a history of fibromyalgia. He reported left shoulder, left knee, and right fifth metacarpal pain. The examiner concluded that "the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in service injury event, or illness." She commented that the "Veteran has no chronic multi joint / fibromyalgia disability (Veteran has specific joint conditions/ injuries)." Service connection for left shoulder impingement syndrome, strain, rotator cuff tendinosis, and dislocation and right fifth metacarpal fracture residuals has been established. A recurrent multiple joint disability was not manifested or diagnosed during active service or at any time thereafter. The reports of October 2019 VA examinations convey that the Veteran denied experiencing and was not found to have a recurrent multiple joint disability. The Board observes that the Veteran did report that he experienced left shoulder, left knee, and right fifth metacarpal pain. Service connection has been established for both left shoulder and right fifth metacarpal disabilities. The Veteran has not submitted a claim for service connection for a left knee disability on the appropriate form. If he seeks service connection for a recurrent left knee disability, he must file a formal claim for that disability. 38 C.F.R. § 3.155. Therefore, the Board concludes that service connection for a recurrent multiple joint disability is not warranted. REASONS FOR REMAND Entitlement to a rating in excess of 30 percent prior to September 6, 2019, and in excess of 50 percent on and after September 6, 2019, for major depressive disorder is remanded. A January 2021 VA mental health clinic treatment record states that the Veteran reported increased psychiatric symptoms including sleep walking. Treating VA medical personnel increased the Veteran psychiatric medications. The Veteran was last afforded a VA psychiatric examination in October 2019. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the reported increase in the service connected psychiatric symptoms necessitating a change in medication, the Board finds that further VA evaluation is needed. Clinical documentation dated after March 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected major depressive disorder. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after March 2021. 3. Schedule the Veteran for a VA psychiatric examination to determine the nature and severity of the service connected major depressive disorder. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should opine as to the impact of the service connected psychiatric disability on the Veteran's vocational pursuits. The examiner should opine as to the levels of occupation and social impairment caused by the psychiatric disability and should describe the symptoms, to include their frequency and severity, that result in those levels of impairment. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.D. Anderson, 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.