Citation Nr: 21073208 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 17-34 047 DATE: December 7, 2021 ORDER Entitlement to service connection for a personality disorder (claimed as gastrointestinal reaction manifested by nausea, vomiting, abdominal cramps, and epigastric pain) is denied. Entitlement to service connection for an acquired psychiatric disorder, claimed as mental problems, anxiety, depression, and posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS), is remanded. Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. Personality disorders are not diseases or injuries for Department of Veterans Affairs (VA) compensation purposes. 2. A preponderance of the evidence of record is against a finding that the Veteran's currently diagnosed acquired psychiatric disorders are related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a personality disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.9, 4.127. 2. The criteria for entitlement to service connection for an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1972 to July 1973. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision issued by a VA Regional Office (RO). These matters were previously before the Board in March 2019 and were remanded for additional development. The case is once again before the Board. Duty to Assist In March 2019, the Board remanded the claims to obtain the Veteran's service treatment records. In February 2021, VA determined that the records could not be located. The Veteran was notified of this finding. A September 2020 report of contact documents that the Veteran did not have any of his service treatment records and was unable to locate the records himself. Accordingly, the Board finds that there has been substantial compliance with the prior remand directives, and no further action is necessary. Since the Veteran's records cannot be located, the VA's duties to assist, to provide reasons and bases for its findings and conclusions, and to carefully consider the benefit-of-the-doubt rule, are therefore heightened. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). SERVICE CONNECTION Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Personality disorder Acquired psychiatric disorder As noted above, the Veteran's service treatment records were lost. Prior to the misplacement of the records, determinations regarding the Veteran's health were made. A June 1973 Medical Board Report stated the Veteran was diagnosed with a psychological gastrointestinal reaction, described as severe and chronic, manifested by nausea, vomiting, abdominal cramps, and epigastric pain. The report found the condition preexisted service and was not aggravated by his service. Based on this report, the Veteran submitted a June 1973 Request for discharge for physical disability. The request contained a signed statement that, "based upon findings of a medical Board convened at USAF Hospital, [redacted], on 12 June 1973, I am considered unfit for world-wide service because of physical disability which is considered to have existed prior to entry on current period of active duty and which appears to be not incident to, or aggravated by, my active military service. I certify that it has been fully explained to me that I am entitled as a matter of right to the same processing as any other member of the Air Force, who is separated for a physical disability including consideration of my case by a physical evaluation board. However, I do not elect to exercise this right." In a November 1976 rating decision for vocational rehabilitation purposes, service connection for a nervous condition was considered. The decision found the Veteran had personality trait disturbance with psychological gastrointestinal reaction. The report stated the Veteran's service medical records indicated that shortly after entry into the military, the Veteran requested a discharge for inadaptability. He was shown to be anxious, with family problems and situational depression. He complained of stomach ailments, but testing was normal. The Veteran reported having problems prior to service, but not to the extent he experienced in service. It was reported that the Veteran had a moderate life-long obsessive-compulsive personality trait disturbance. The decision concluded the Veteran's problems stem from personality trait disorder and was not aggravated during service and constitutional or developmental abnormality is not a disability under the law. In January 2015, the Veteran was diagnosed with an unspecified anxiety disorder, with depression listed as a symptom. The examiner noted the Veteran was especially depressed at the first of the month when his bills arrived. The examiner found the Veteran's anxiety disorder at least as likely as not a continuation of the anxiety symptoms the Veteran was treated for in service. The examiner also ruled out maladaptive personality traits with cluster C features, finding that there was no history of functional impairments prior to his service. The examiner stated that the Veteran was a reliable informant and that there is no evidence of impairment prior to military service that would support the diagnosis of a personality disorder. In February 2015, an examiner concluded the Veteran's psychological gastro-intestinal reaction was a condition more likely than not a personality disorder that existed prior to the Veteran's service and less likely than not aggravated beyond its natural progression by his service. The examiner reasoned that the Veteran's symptoms were consistent with a personality disorder and not a mental health disorder and the difficulties described in service were consistent with characteristic expressions of a personality disorder rather than discrete psychological reactions of separate mental health symptoms. VA compensation may not be paid for a personality disorder, as it is specifically excluded as a disease or injury within the meaning of applicable regulations. See 38 C.F.R. §§ 3.303(c), 4.9. Therefore, to the extent the evidence of record requires the Board to consider whether service connection may be warranted for the Veteran's diagnosed personality disorder (claimed as gastrointestinal reaction manifested by nausea, vomiting, abdominal cramps, epigastric pains), the Board must deny that aspect of the Veteran's acquired psychiatric disorder claim as a matter of law. Nevertheless, a superimposed acquired psychiatric disorder resulting from such personality disorder or representing an aggravation of the disorder may be service connected. See 38 C.F.R. § 4.127. Although the Veteran was found to have a diagnosis of generalized anxiety disorder, as will be discussed below, the preponderance of the evidence of record establishes that his anxiety was not due to service and is a symptom of his personality disorder. The January 2015 VA examiner stated that the Veteran's anxiety was a continuation of the Veteran's symptoms in service. That same examiner found the Veteran did not have a personality disorder in service that preexisted his service. The Board finds the opinion that the Veteran's anxiety is a continuation of the anxiety symptoms he was treated for in service probative; however, the examiner's finding that the condition did not predate service is outweighed by the other evidence of record, to include the November 1976 decision (that reviewed the Veteran's service treatment records) and the Veteran's own acknowledgements that his condition predated service. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). While discussing the Veteran's pre-military, military, and post-military history, the examiner documented that the Veteran had a psychophysiologic gastrointestinal reaction during service and that he reported having this problem prior to service, just not as severe. Elsewhere in the opinion, the examiner stated there was no evidence of a preexisting problems and that his gastrointestinal issues began during service. Due, in part, to the internal inconsistency, the opinion is offered less probative value than the February 2015 examination report. In this regard, while the Veteran asserted that he did not have health problems prior to service, the Board finds his statements made in June 1973 declaring that his condition preexisted service to be more credible and probative than statements made almost 40 years after service to VA for purposes of seeking compensation. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). As shown above, the June 1973 signed statements were made on an official request for discharge for physical disability and state the condition existed prior to entry of active duty and which appears to be not incident to, or aggravated by, active military service. Moreover, as noted above, the November 1976 examiner had the service treatment records, and reported that the Veteran experienced gastrointestinal issues prior to service. Thus, the Veteran's recent contradicting statement that his condition did not predate service is not credible. To the extent the Veteran claims he has PTSD, service connection is not warranted because the preponderance of evidence indicates that the Veteran has not had a PTSD diagnosis that conforms with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria at any time during the appeal period. The Board acknowledges the Veteran has not been afforded a VA examination with respect to this claim. Pursuant to McLendon v. Nicholson, a VA examination must be provided when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing an event, injury or disease occurred in service, and (3) an indication that the disability or persistent or current symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent evidence of record to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Aside from the Veteran listing PTSD on the claim form, there is no indication that the Veteran has a diagnosis of PTSD. While the Veteran is competent to report his symptoms, he is not competent to diagnose himself with PTSD. The issue is medically complex, as it requires knowledge of a trained clinician. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Moreover, the record contains negative PTSD screenings. See July 2011 and July 2016 treatment records. The Board also finds the February 2015 VA examination report to be more probative than the notations in the Veteran's outpatient treatment records which document anxiety and depression. The opinion contained in the examination report is supported by reasons and bases and was made following a review of the claims file. In contrast, the outpatient treatment records were not rendered following such a review and do not address the history of his personality disorder. This is significant because treatment records document that the Veteran complained that "I have depression and anxiety" and was diagnosed with depression and anxiety in January 2017. He reported worrying all the time and was diagnosed with chronic anxiety in November 2016. The treatment records do not indicate that the clinicians were aware of the Veteran's personality disorder. In sum, the Board places greater weight of probative value on the February 2015 examiner's opinion which is internally consistent and consistent with the evidence of record. The preponderance of the evidence reflects the Veteran's anxiety symptoms are related to his personality disorder and is not a discrete psychological reaction of a separate mental health condition or otherwise related to his service. Accordingly, as the preponderance of the evidence of record reflects that the Veteran's anxiety disorder is a symptom of the Veteran's personality disorder which clearly and unmistakably preexisted service and was not aggravated by service, entitlement to service connection for an acquired psychiatric disorder is not warranted. The Veteran's claim is therefore denied. REASONS FOR REMAND Gastrointestinal disorder The Veteran maintains his gastrointestinal condition began while on active duty. As shown above, the Veteran was diagnosed with a psychophysiological personality disorder manifested by nausea, vomiting, abdominal cramps, and epigastric pain. VA treatment records indicate the Veteran underwent a colonoscopy in March 2010, revealing no polyps or other abnormalities. Private treatment records indicate the Veteran underwent two additional colonoscopies. One in March 2011, revealing polyps, and another in June 2014, revealing mild diverticulitis and a small hiatal hernia. In January 2015, a VA examiner diagnosed the Veteran with irritable bowel syndrome and gastroesophageal reflux disease (GERD) that began in the 1970s. The examiner stated she was unable to give an opinion regarding etiology without review of the service treatment records. In February 2015, a VA examiner found, based on a review of the Veteran's claims file and his most recent examination, the Veteran's current gastrointestinal condition was present prior to service and persisted in service. The examiner found no evidence that the condition worsened beyond its natural progression and was not aggravated beyond its natural progression in service. Later in February 2015, a second examiner concluded the Veteran's psychological gastrointestinal reaction was a condition more likely than not a personality disorder that existed prior to the Veteran's service and less likely than not aggravated beyond its natural progression by his service. The examiner reasoned that the Veteran's symptoms were consistent with a personality disorder and not a mental health disorder and the difficulties described in service were consistent with characteristic of expressions of a personality disorder rather than discrete psychological reactions of separate mental health symptoms. The Board cannot make a fully informed decision on the issue of entitlement to service connection for a gastrointestinal disability because the record does not contain an opinion addressing all of the Veteran's diagnoses. In 2010, the Veteran's colonoscopy results appear normal. Four years later, diverticulitis and a hiatal hernia are noted. The above referenced opinions do not address these results. Accordingly, remand is necessary to obtain an addendum opinion regarding whether the Veteran's diverticulitis or hiatal hernia are related to his service or a manifestation of his personality disorder. The Veteran has not authorized the Board to obtain his private gastrointestinal records prior to April 2014. See May 2014 VA Form 21-4142 Authorization and consent to release information. Since the claim is being remanded for further development, the Veteran should be afforded an opportunity to submit, or authorize VA to obtain, his private treatment records prior to 2014. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. Hypertension The Veteran contends, in part, that he developed high blood pressure as a result of his gastrointestinal problems. See May 2014 Statement in support of claim. As the issue of entitlement to service connection for hypertension can be impacted by resolution of the Veteran's gastrointestinal claim, the Board finds that the issue of entitlement to service connection for hypertension must also be remanded. The matters are REMANDED for the following action: 1. Contact the Veteran to determine if there are any outstanding, relevant private treatment records prior to 2014. If so, undertake all appropriate development necessary to obtain the records from each private treatment provider and/or facility identified by him. 2. Arrange for an appropriate healthcare provider to review the file and, for the period of appeal, identify any symptoms attributable to a gastrointestinal disorder. For each identified diagnosis, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed condition had causal origins in service or is otherwise related to the Veteran's active-duty service. The examiner's attention is drawn to the 2010 and 2014 colonoscopy results and IBS treatment records. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. 3. After undertaking any additional development deemed appropriate and giving the Veteran full opportunity to supplement the record, adjudicate the Veteran's pending claim in light of any additional evidence added to the record. If any benefit sought on appeal remains denied, the Veteran should be furnished with a Supplemental Statement of the Case and be afforded the applicable opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.V. Palatt, Associate 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.