Citation Nr: 21066215 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 17-55 262 DATE: October 29, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizoaffective disorder (but excluding PTSD, depression, and anxiety), is remanded. FINDING OF FACT The Veteran does not have, and has not had, a diagnosis of PTSD throughout the course of this appeal. CONCLUSION OF LAW The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1985 to March 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. In April 2021, the Board remanded this matter for additional development. Entitlement to service connection for PTSD is denied. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (1996). Service connection for 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 claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). VA regulations require evaluation of mental disorders using the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-5). 38 C.F.R. §§ 4.125, 4.126. Having carefully considered the Veteran's claim in light of the record and the applicable law, the Board finds that the preponderance of the evidence is against the claim of service connection for PTSD. Although the Board has conceded one of the Veteran's stressors, namely the events surrounding his now service-connected back disability, there is no confirmed diagnosis of PTSD in the record for the applicable appeal period. The Board notes that a few VA treatment records include a diagnosis of PTSD as part of the Veteran's medical history. However, PTSD screenings in February 2006, May 2011, and April 2015 were all negative. A VA mental health assessment in June and July 2013 noted that the Veteran did not meet the full criteria for PTSD; psychiatric diagnoses included major depressive disorder, alcohol abuse, and rule out schizoaffective disorder. An August 2013 VA mental health record included symptoms for PTSD, but diagnoses included schizoaffective disorder, depressive type, and alcohol dependence in early remission. In a June 2021 initial PTSD disability benefits questionnaire (DBQ), the examiner diagnosed schizoaffective disorder, concluding that the Veteran does not meet the criteria for PTSD. An addendum opinion was requested because the examiner did not identify the unmet criteria and did not reconcile her conclusion with the diagnosis of PTSD noted in private treatment records. In a July 2021 VA addendum opinion, the examiner noted that a majority of the record across 2014 to the present do not support an active diagnosis of PTSD, but instead supports a consistent diagnosis of schizoaffective disorder. She concluded that, prior to that period, from 2010 to 2012, it would be speculation to discuss whether the Veteran met the criteria for PTSD since a comprehensive evaluation was not included in the record. While he may have been diagnosed with PTSD related to work related injuries at "some point," a PTSD diagnosis is not relevant nor accurate to describe his current symptom manifestation. The Veteran's private treatment records prior to the appeal period note a diagnosis of PTSD and relate such to a workplace hate crime, not military service. See generally August 2009 psychological assessment and May 2013 psychiatric consultation. As outlined by the June 2021 VA examiner, the record is silent for a PTSD diagnosis during the appeal period that is supported by a comprehensive evaluation. In fact, the opposite is true: VA psychologists who conducted psychological assessments during the appeal period did not diagnose PTSD, noting that while the Veteran met some of the symptoms of PTSD, he did not meet the full criteria for a diagnosis of PTSD. The Board acknowledges the Veteran's reports of mental health symptoms associated with his conceded stressor, and is in fact remanding a claim of entitlement to service connection for schizoaffective disorder for additional development. However, with respect to his claim of service connection for PTSD, as a layperson, he does not possess the medical expertise required to provide a diagnosis. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Moreover, as noted above, service connection for PTSD specifically requires medical evidence diagnosing the disability. The record does not show a diagnosis of PTSD during the appeal period. As with all claims for service connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020) (holding that with respect to psychiatric disabilities, VA has expressly limited compensation to disabilities conforming to a DSM-5 diagnosis). Service connection for PTSD is therefore not warranted. 38 C.F.R. § 3.303. REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder, to include schizoaffective disorder (but excluding PTSD, depression, and anxiety), is remanded. In its April 2021 remand, the Board requested an opinion addressing all psychiatric disabilities present during the appeal period and an opinion as to whether such disabilities were (a) related to a stressor event in service, including a conceded stressor, or (b) caused or aggravated by the Veteran's service-connected back disability. In a June 2021 initial PTSD DBQ, the examiner diagnosed schizoaffective disorder and opined that it is less likely that such is related to service since there is no evidence that such is related to service or the "traumatic incidences that he tells of having occurred in the service." In a July 2021 VA addendum opinion, the examiner stated that it would be speculation to address whether the Veteran's schizoaffective disorder was worsened beyond its natural course by miliary service or service-connected disabilities. She explained that schizophrenia is a chronic and often debilitating mental health diagnosis that commonly includes persecutory themes, such as those present in his record, "thematic in his report of trauma events." It is possible that his reports of trauma are a symptom of his schizophrenia, but this would be speculation. The examiner also stated that it is "well-known across the literature on schizophrenia that life stress and individual's personal circumstances can exacerbate symptoms and increase relapse/worsening of symptoms." Chronic health conditions can "certainly play (sic) a role in exacerbating [a] mental health disorder" but there is no evidence of such in his treatment record or in evaluation. Accordingly, she opined that it is less likely that the Veteran's schizoaffective disorder is worsened beyond its natural course by his service-connected back disability. The Board finds this medical opinion inadequate as it ignores the Veteran's testimony that the pain from his service-connected back disability worsens his psychiatric symptoms, as well as a July 2013 VA initial mental health evaluation wherein the Veteran reported first experiencing symptoms of depression, irritability, paranoia, and auditory hallucinations following two incidents in the military, including the incident surrounding his service-connected back disability. The Board finds that the examiner failed to provide adequate rationale as to (1) why the Veteran's schizoaffective disorder is less likely related to service in light of the foregoing and (2) why such is less likely caused or aggravated by his service-connected disability. Accordingly, a new opinion is warranted. The matter is REMANDED for the following action: 1. Arrange for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to determine the nature and likely cause of his schizoaffective disorder. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a) Is it at least as likely as not (50% or greater probability) that the Veteran's schizoaffective disorder was either incurred in or otherwise related to his military service, to specifically include the established stressor involving a helicopter incident? In answering this question, the examiner's attention is directed to the following: May 2013 VA treatment record: the Veteran was depressed since he was hurt in Korea and drank to forget and block out memories of that time; July 2013 VA treatment: the Veteran first began experiencing symptoms of depression, irritability, paranoia, and auditory hallucinations following an incident with his Captain and following the back injury during service; and November 2014 statement: the helicopter incident caused nightmares and flashbacks ever since; the Veteran started drinking heavily following this incident and continued to self-medicate for 10 to 15 years before seeking professional help. (b) If not, then is at least as likely as not (50% or greater probability) that such disability was either caused or aggravated by the Veteran's service-connected back disability? The examiner is reminded that the Veteran testified that the pain from his service-connected back disability worsens his psychiatric symptoms. The examiner's attention is also directed to a July 2013 VA initial mental health evaluation wherein the Veteran reported first experiencing symptoms of depression, irritability, paranoia, and auditory hallucinations following two incidents in the military, including the incident surrounding his service-connected back disability. The opinion must address whether the psychiatric disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, please identify to the extent possible the baseline level of disability prior to the aggravation. (CONTINUED ON NEXT PAGE) 2. If upon completion of the above action the issue remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Matta, 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.