Citation Nr: 21070754 Decision Date: 11/26/21 Archive Date: 11/25/21 DOCKET NO. 17-59 794 DATE: November 26, 2021 ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT An acquired psychiatric disorder, to include PTSD, is not shown to be causally or etiologically related to any disease, injury, or incident during service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 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 from August 1987 to March 1992. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in December 2015 by a Department of Veterans' Affairs (VA) Regional Office. In January 2020, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In April 2020 and May 2021, the Board remanded the case for additional development and it now returns for further appellate review. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD. 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 a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 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). If a claimed stressor is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances 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)(3). The Veteran contends that he has an acquired psychiatric disorder, to include PTSD, related to his military service. Specifically, he reports that, while serving in Germany from May 1988 to May 1990, one of the military policemen, Specialist Simon, threatened suicide, which caused the base to be locked down in June 1989, and, as a result of heightened tensions during the fall of the Berlin Wall beginning in November 1989, his unit was subject to base restrictions/lockdowns and numerous combat alerts. In regard to the latter experience, the Veteran reported that, as part of his duties of his military occupational specialty of automatic data telecommunications center operator, he monitored highly classified communications regarding the movements of troops and political leaders, and was fearful of potential nuclear, biological, and/or chemical attacks. While the Veteran's service treatment records are negative for any complaints, treatment, or diagnoses referable to an acquired psychiatric disorder, he and his spouse, who knew him prior to service and re-met him in 1992, reported the onset of psychiatric symptoms, to include hypervigilance, coincident to his military service. Post-service VA treatment records reflect that, in June 2004, PTSD and depression screens were negative. Rather, the Veteran first sought treatment for psychiatric complaints in May 2011. At such time, he reported that, while stationed in Germany, another service member threatened suicide. However, he also indicated that, during his childhood, his family home was filled with episodes of abuse and violence due to his fighting parents, he was mentally abused by both parents, his childhood home burned down, and he was bullied at school. A physician's assistant diagnosed PTSD related to childhood trauma, depression not otherwise specified (NOS), anxiety NOS, and obsessive compulsive disorder (OCD). In August 2011, the Veteran reported that he was stationed in Germany during the time the Berlin Wall was being torn down and was on heightened alert for possible nuclear, biological, and chemical warfare attacks. He indicated that he was fearful of the viruses and chemicals used in such attacks. At such time, his treating physician's assistant diagnosed PTSD due to childhood trauma and military service, depression NOS, anxiety NOS, and OCD. Such diagnoses have been carried forward during subsequent treatment sessions. Further, in October 2014, the Veteran's treating physician's assistant offered a statement that related the Veteran's diagnosis of PTSD to his military service, to include the aforementioned attempted suicide by a fellow service member and his participation in disaster alerts for nuclear, biological, and chemical warfare attacks. At a September 2017 VA examination, the examiner, a psychologist, found that the Veteran did not meet the American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition, (DSM-5) criteria for a diagnosis of PTSD related to military service as his reported stressor of serving in Germany when the Berlin Wall was torn down did not conceptually meet the stressor criterion and, even if it did, there was no evidence of re-experiencing symptoms of such event that would substantiate a diagnosis of PTSD related to such experience. Furthermore, she noted that the Veteran had been diagnosed with PTSD, but such was related to childhood trauma. In this regard, the examiner noted that, while the Veteran did not endorse childhood trauma on examination, the aforementioned VA treatment records record an extensive history of childhood trauma. Additionally, while the Veteran was diagnosed with unspecified anxiety disorder at the VA examination, the examiner opined that, as VA treatment records indicate a clear nexus between the Veteran's current symptoms and childhood trauma, and there was no clear nexus between such symptoms and military service, such disorder was less likely than not caused by or related to military service. However, at the January 2020 Board hearing, the Veteran reported that, while there was domestic violence in his house growing up, he was not bothered by such experiences. Rather, as noted previously, he and his spouse reported the onset of psychiatric symptoms coincident to his military service, to include hypervigilance. Additionally, in a January 2020 private evaluation, which was conducted by a VA-trained and certified psychologist, the Veteran's report regarding his father's abuse of his mother and his stressful experiences while stationed in Germany when the Berlin Wall came down were noted; however, in regard to Criterion A for a diagnosis of PTSD, exposure to actual or threatened death, serious injury, or sexual violence, the examiner only observed that the Veteran directly experienced the traumatic event. She did not identify or describe the stressor. Nonetheless, she ultimately found that the Veteran's PTSD was incurred in or caused by his in-service stressor of fear of hostile military or terrorist activity. In the April 2020 remand, the Board found that, while the January 2020 private psychologist found that Veteran directly experienced a traumatic event and related his PTSD to his fear of hostile military or terrorist activity, she did not identify the specific stressor. Additionally, while the September 2017 VA examiner found that the Veteran's reported in-service stressor regarding his experiences in Germany during the fall of the Berlin Wall did not meet Criterion A for a diagnosis of PTSD, it was unclear whether such meet VA's definition of fear of hostile military or terrorist activity so as to be sufficient to support a diagnosis of PTSD under the DSM-5. Further, while she diagnosed unspecified anxiety disorder, which she found was unrelated to the Veteran's military service, neither she nor the January 2020 private psychologist addressed the other psychiatric diagnoses of record, to include depression NOS and OCD. Finally, the Board found that the evidence was in conflict as to the nature and impact of the Veteran's reported childhood trauma on his current psychiatric disorder. Consequently, the Board remanded the case so as to afford the Veteran a new VA examination so as to determine the nature and etiology of his claimed acquired psychiatric disorder. In July 2020, the Veteran underwent a new VA examination, at which time the examiner found that he did not have a diagnosis of PTSD pursuant to DSM-5 as Criterion A had not been met, i.e., there was no exposure to actual or threatened a) death, b) serious injury, or c) sexual violation. In this regard, she found that the Veteran's experiences while stationed in Germany that reportedly resulted in fear of potential nuclear, biological, and/or chemical attacks were not related to a fear of hostile military or terrorist activity and, therefore, insufficient to support a diagnosis of PTSD under the DSM-5. In support of such determination, she noted that fear of potential events does not rise to the level of Criterion A for a diagnosis of PTSD under DSM-5 because such specifies fear that occurs during or soon after an actual traumatic event. Rather, the examiner diagnosed unspecified anxiety disorder, but opined that the Veteran's medical records did not support a finding that such disorder was incurred in or caused by fear for life from hostile forces during service, the threat of suicide by another service member, and/or his experiences while stationed in Germany during the fall of the Berlin Wall. In this regard, she noted there was no report of mental health issues during the Veteran's service time and no consistent report of ongoing mental health problems since military service. She further found it pertinent that the Veteran did not seek mental health treatment until decades after service. The examiner further explained that the Veteran did not claim symptoms consistent with the DSM-5 criteria for diagnoses of OCD or depression NOS on examination. She also found that there was no evidence reported in the examination suggesting that any of the Veteran's childhood events caused mental health problems prior to service as evidenced by his level of functioning related to school and employment, his lack of legal problems and functional impairment prior to entering service, and medical literature. In the May 2021 remand, the Board noted that the absence of evidence of complaints, treatment, or a diagnosis referable to an acquired psychiatric disorder in the Veteran's service treatment records cannot serve as the sole basis for a negative opinion. Likewise, a lack of post-service treatment records demonstrating a continuity of care cannot form the sole basis of a negative opinion. The Board found such principle to be particularly significant in the instant case in light of the Veteran's testimony that he and his spouse noticed psychiatric symptoms coincident to his military service in 1992. Additionally, although the July 2020 VA examiner found the only diagnosis applicable to the Veteran's current symptoms was unspecified anxiety disorder, VA treatment records dated as recently as September 2017 reflect active problems of recurrent depression and OCD. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). Therefore, the Board found that a remand was necessary to obtain an addendum opinion that addresses the Veteran's and his spouse's lay statements regarding his in-service and post-service symptoms as well as the additional diagnoses of acquired psychiatric disorders rendered during the pendency of the appeal. Thereafter, in June 2021, the July 2020 VA examiner reviewed the record and provided an addendum opinion responsive to the Board's inquiries. In this regard, she noted that, upon review of the May 2011 VA treatment record wherein diagnoses of PTSD, OCD, anxiety NOS, and depression NOS were diagnosed, there was no indication as to how the provider came to such diagnoses as there was no support for them in the assessment. In this regard, the examiner noted that the DSM-5 is clear that, for each diagnosis, several symptoms have to be meet within a certain time frame; however, such was not reported in any of the treatment records. Moreover, no depression symptoms were noted, and the Veteran denied suicidal ideation and feelings of hopelessness and helplessness, which weighs against a diagnosis of depression NOS. Similarly, she found that there was no support for a diagnosis of OCD with the exception of the Veteran's statement that he likes to have things in order. In this regard, the examiner explained that, to render a diagnosis of OCD, there must be objective indications of such disease, rather than the Veteran's single subjective statement. Moreover, she indicated that the physician did not consider whether there was a reason other than OCD for the Veteran's symptoms, to include obstructive sleep apnea (OSA) as untreated OSA can cause many symptoms that overlap with psychiatric symptoms. Finally, the examiner observed that no other provider has reported any findings that would support a diagnosis of depression NOS or OCD. Consequently, she concluded that there was insufficient objective evidence to support a finding that the Veteran ever had a diagnosis of such disorders at any time proximate to his February 2015 claim. The examiner further opined that the Veteran's currently diagnosed unspecified anxiety disorder was less likely than not incurred in or caused by the Veteran's military service, to include the threat of suicide by another service member and/or his experiences while stationed in Germany during the fall of the Berlin Wall. In this regard, she noted that there was no report of mental health problems or treatment during the Veteran's military service or at any time since separation from service in 1992 and the late 2000's. Furthermore, the examiner observed that the Veteran was in a successful relationship, was doing well at work, and obtained a college degree with an above average GPA. She also indicated that the Veteran's reported in-service stressors did not rise above the level of normal military or life stressors and, thus, were unlikely to have contributed to the origin of his mental health diagnosis. In reaching such determination, the examiner considered the Veteran's and his spouse's lay statements detailing the onset of psychiatric symptoms coincident to his military service, to include hypervigilance; however, she found that there was no objective evidence in the record to support such reported onset. Moreover, she indicated that hypervigilance is a symptom of PTSD, but can also be seen in other disorders and conditions, to include anxiety, OSD, substance abuse, and personality disorders. The examiner further explained that many lay people misunderstand the psychiatric definition and use it as a general term for many types of anxious or normal behaviors such as being wound up and on edge, irritability, caution, concern, neat and orderly, new parent concerns, etc. Thus, she found that the Veteran and his spouse could have used the term inaccurately and thus the reported onset of could also be inaccurate. In further support of such determination, she noted that, while a VA treatment record in the 2000's reflects a description of what could be hypervigilance, there was no objective evidence that such behavior began such time. The examiner further opined that the Veteran's reported in-service stressors did not meet Criterion A for a diagnosis of PTSD under the DSM-5. In this regard, she observed that such stressors were based on fears of what could have or might have happened. However, Criterion A is clear that a stressor has to have occurred in order to be considered an origin of PTSD. Therefore, the examiner found that the Veteran did not have a diagnosis of PTSD based on his reported in-service stressors. The Board affords great probative weight to the September 2017, July 2020, and June 2021 VA examiners' opinions as such collectively considered all of the pertinent evidence of record, to include the Veteran's and his spouse's statements and his relevant medical history, to include all diagnoses of record, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In contrast, the Board affords no probative weight to May 2011/August 2011 assessments of depression NOS and OCD, and the diagnosis of PTSD related to military service at such time and in October 2014 as such was rendered by a physician's assistant rather than a psychologist or psychiatrist, the latter of which has specialized education and training in the diagnosis of psychiatric disorders. Moreover, as detailed by the highly probative June 2021 VA examiner's opinion, the diagnoses of depression NOS and OCD are unsupported by the objective evidence of record, and the Veteran's reported in-service stressors are insufficient to support a diagnosis of PTSD under the DSM-5. Id. Similarly, the Board affords the January 2020 private evaluation concluding that the Veteran had a diagnosis of PTSD that was incurred in or caused by his in-service stressor of fear of hostile military or terrorist activity no probative weight. Specifically, while such was conducted by a VA-trained and certified psychologist, she did not identify the specific stressor upon which such diagnosis was based. Id. The Board also considered the Veteran's and his spouse's assertions as to the etiology of his acquired psychiatric disorder; however, as lay people, they do not have the requisite training and experience necessary to address such a complex medical matter. 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). In this regard, the etiology of such disorder involves a medical subject concerning an internal psychiatric process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Moreover, whether the symptoms the Veteran reportedly experienced during or after service, to include hypervigilance, are in any way related to his currently diagnosed acquired psychiatric disorder is a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Accordingly, the Veteran's and his spouse's opinions as to the onset and etiology of his acquired psychiatric disorder is not competent evidence and, consequently, is afforded no probative weight. Based on the foregoing, the Board finds that an acquired psychiatric disorder, to include PTSD, is not shown to be causally or etiologically related to any disease, injury, or incident during service. Consequently, service connection for such disorder are not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Spielmann, Jill F. 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.