Citation Nr: 21064535 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 20-12 451 DATE: October 20, 2021 ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), claimed also as secondary to service-connected peptic ulcer disease, is denied. FINDING OF FACT An acquired psychiatric disorder did not manifest in service and is not otherwise shown to be related to service or a service-connected disability, including peptic ulcer disease. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, claimed also as secondary to service-connected peptic ulcer disease, is not met. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1951 to November 1953. A virtual hearing was held before the Board of Veterans' Appeals (Board) in October 2020. A hearing transcript is of record. In April 2021 and July 2021, the Board, in pertinent part, remanded the issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, claimed also as secondary to service-connected peptic ulcer disease, for additional development. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish service connection, a Veteran must show: (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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially 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). Secondary service connection is also warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, claimed also as secondary to service-connected peptic ulcer disease The Veteran contends he suffers from an acquired psychiatric disorder, to include PTSD, as a result of his service-connected peptic ulcer disease. Specifically, at the Board hearing, the Veteran clarified that he was not seeking service connection for his condition as a direct result of his military service. Instead, he testified that his current stress and anxiety was a result of his service-connected ulcers/nerves which caused him to feel anxious. He described his anxiety as manifesting in difficulties sleeping and feeling like his nerves were shot. He also reported that he had been taking medication for anxiety for 40 years. See October 2020 Hearing Transcript and see March 2017 Statement in Support of the Claim. During the April 2021 VA examination, the Veteran was given a diagnosis of unspecified depressive disorder. Therefore, the Veteran has a currently diagnosed acquired psychiatric disorder. However, the Veteran's service treatment records are silent for any complaints, findings, treatment, or diagnosis relating to depressive disorder, anxiety disorder, or any other acquired psychiatric disorder. As such, there is no evidence that the Veteran's current acquired psychiatric disorder had its onset in service or is otherwise directly related to his military service. Moreover, the Veteran and his representative specified at the October 2020 Board hearing that he was not alleging that his condition was a direct result of his military service. Consequently, service connection for an acquired psychiatric disorder, to include PTSD, on the basis that such became manifest in service is not warranted. 38 C.F.R. § 3.303(d). As to the secondary service connection claim, the Board finds the preponderance of the evidence is against a finding that the Veteran's acquired psychiatric disorder is etiologically related to his service-connected peptic ulcer disease. In April 2021, the Veteran was afforded a VA examination. The examiner diagnosed an unspecified depressive disorder and noted that the medical diagnoses relevant to the understanding or management of that mental health disorder consisted of peptic ulcer disease. The examiner indicated that due to the peptic ulcer, discomfort might result in irritability or mood change. See April 2021 VA examination. In the associated medical opinion, however, the VA examiner opined that the Veteran's unspecified depressive disorder was not at least as likely than not proximately due to or the result of the service-connected peptic ulcer disease. The examiner explained that a review of the claims file did not show any depression or mental health problems associated with peptic ulcer disease and noted that the Veteran's peptic ulcer disease occurred in 1964 while depression screens in 2002, 2012, 2014, and 2015 were negative. The examiner also noted that a clinical interview conducted in April 2021 revealed that the Veteran had moderate cognitive impairment coupled with depression, and that the Veteran had a history of strokes. For these reasons, the examiner concluded the Veteran's psychiatric problems were not related to, or due to the peptic ulcer diagnosis, but rather the depressive symptoms were likely the result of his decline in cognitive abilities. The examiner similarly opined the Veteran's unspecified depressive disorder was not at least as likely as not aggravated beyond its natural progression by his service-connected peptic ulcer disease. The examiner again explained that the unspecified depressive disorder was related to the Veteran's cognitive decline, which was precipitated by recent medical problems. See April 2021 VA medical opinion. In July 2021, the Board noted that the April 2021 VA examiner did not specifically address whether the Veteran's peptic ulcer disease, which was conceded in the examination report to cause irritability or mood change, might also be aggravating his diagnosis of unspecified depressive disorder. Therefore, a medical addendum opinion was requested. In an August 2021 VA medical addendum opinion, a VA examiner reviewed the Veteran's claims file and opined that the claimed condition was less likely as not due to or the result of the Veteran's service-connected peptic ulcer. The examiner explained that the evidence of record showed the Veteran first reported intermittent depression in December 1987 and was prescribed an antidepressant medication at that time. He did not discuss his peptic ulcers during his mental health appointments when he established mental health treatment. Rather, his medical records documented that he reported increased symptoms related to situational life stressors including his marriage, finances, and family worries. He also reported depression symptoms within the context of sexual dysfunction. However, a review of the Veteran's medical records since the 1980s showed he never reported depression due to his peptic ulcers. The examiner noted that although the peptic ulcers were a chronic condition, there were many years from the early 1990s through 2014 when the Veteran consistently denied depression symptoms despite his peptic ulcer condition. The examiner also acknowledged that in the April 2021 VA examination report it had been commented that peptic ulcers may result in irritability or mood change and stated it was true that pain can cause irritability and mood fluctuations. However, the examiner noted this was a normal experience and did not necessarily rise to the level of a mental disorder. In the case of the Veteran, examiner observed that the evidence of record did not support a nexus between his unspecified depressive disorder and his peptic ulcers in that medical records since the late 1980s showed he had longstanding, intermittent, mild depression that he never reported as related to his peptic ulcers. The examiner noted that the first comment of the Veteran's peptic ulcers possibly causing irritability or mood change was in the April 2021 examination report. Therefore, the examiner concluded that while pain associated with peptic ulcers pain, might cause irritability, or mood fluctuation, this was a normal experience and the evidence of record did not demonstrate that the Veteran's peptic ulcers caused his unspecified depressive disorder, which dated back to the 1980s. Rather, the evidence of record demonstrated that the Veteran had longstanding, intermittent depression, that was independent of his peptic ulcers given he had evidenced depression for many years with no documentation of the depression being related to his peptic ulcers and years during which he denied depressive symptoms despite his chronic peptic ulcer disease. The examiner stated the evidence of record did not support a nexus between the Veteran's unspecified depressive disorder and his service-connected peptic ulcers. See August 2021 VA medical opinion. Regarding aggravation, the April 2021 VA examiner found that the Veteran's baseline generalized anxiety disorder and unspecified depressive disorder were mild based upon the fact that the medical records showed he evidenced symptoms causing significant enough distress to rise to the level of diagnosis, medication management and occasional mental health treatment, but that there was no significant functional impairment due to anxiety or depression throughout the years. The examiner noted that when the Veteran was seen for mental health treatment in December 1987 for anxiety and depression, he did not feel his nervousness was different from most people, he denied the need for psychotherapy, he reported intermittent depressed mood, he benefitted from an antidepressant medication, and he denied dysfunction in his life, which was consistent with mild anxiety and depressive disorders. The examiner then stated that regardless of the established baseline, it was less likely as not that the Veteran's unspecified depressive disorder was aggravated beyond its nature progression by his service-connected peptic ulcers. In support of that opinion, the examiner explained that during the April 2021 VA examination, the Veteran was formally diagnosed with an unspecified depressive disorder and was observed to have mild dysphoria with the Veteran denying feeling sad and no reports of being prescribed antidepressant medication; therefore, this was consistent with mild depressive symptoms. The examiner also stated that while the April 2021 VA examiner did not formally diagnose an anxiety disorder, the Veteran's longitudinal records showed a longstanding diagnosis of generalized anxiety disorder dating back to the late 1980s, and he reported that he continued to be prescribed antianxiety medication. The Veteran denied feeling anxious. Therefore, the examiner stated that while not diagnosed by the VA examiner, the Veteran had longstanding anxiety, that was well controlled with medication for the past 40 years. The examiner noted that the only symptoms endorsed relating to the Veteran's generalized anxiety disorder and unspecified depressive disorder were depressed mood and anxiety, and given that he was maintained on an antianxiety medication only, did not require specialized mental health treatment, and did not evidence functional impairment due to anxiety or depression, his symptoms were consistent with mild depression symptoms and mild anxiety with transient symptoms that were well controlled with medication, and consistent with his baseline anxiety and depression symptoms. The examiner then stated that although the April 2021 VA examiner had commented that the Veteran's peptic ulcer might result in irritability or mood change, this was a normal reaction to pain and did not indicate an aggravation of the Veteran's longstanding anxiety or depression. The examiner noted that the Veteran had longstanding intermittent irritability and mood change associated with his generalized anxiety disorder and unspecified depressive disorder since the 1980s and the April 2021 VA examination report continued to document mild depression and anxiety symptoms that were well controlled with medication, consistent with his baseline. Therefore, the evidence did not support a finding that there was an aggravation of the Veteran's longstanding anxiety and depressive disorders beyond the naturel progression of the disorders due ot his service-connected peptic ulcers. See August 2021 VA medical addendum opinion. After reviewing the foregoing medical opinions, the Board concludes that the August 2021 VA examiner's addendum opinions are most probative because they are based on a thorough review of the claims file, are based on an accurate understanding of the Veteran's medical history, and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Significantly, the examiner acknowledged and explained that any irritability or mood change caused by the Veteran's peptic ulcer is a normal reaction to pain and does not cause or result in aggravation of his longstanding anxiety or depression, both of which pre-date any discussion of pain associated with the peptic ulcer disease. Additionally, it has been highlighted both by the August 2021 and April 2021 VA examiners that despite reporting intermittent depression in December 1987 which required medication, the Veteran did not discuss his peptic ulcers. Instead, his medical records document that he reported increased symptoms related to situational life stressors including his marriage, finances, and family worries. Finally, the Board notes that there is no competent evidence contrary to the medical opinions of record. Although the Veteran contends his acquired psychiatric disorder is related to his peptic ulcer disease, as a layperson, he is not competent to render a medical opinion in this case. The question of whether one disability is related to another is medically complex in nature. Consequently, he is not competent to opine as to the etiological relationship between his acquired psychiatric disorder and his peptic ulcers. As there is no other competent evidence of record indicating a nexus between an acquired psychiatric disorder and military service or any of the Veteran's service-connected disabilities, the Board finds that a preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder, to include PTSD, claimed as secondary to service-connected peptic ulcers. As such, the benefit-of-the-doubt doctrine is not for application and the claim for service connection must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Churchwell, 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.