Citation Nr: 21074677 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 15-06 639 DATE: December 16, 2021 ORDER Service connection for an acquired psychiatric disorder is denied. FINDINGS OF FACT 1. The Veteran served on active duty from April to October 1960, October 1961 to August 1962, and November 1990 to July 1991; he died in 2018 and his surviving spouse has been properly substituted as the appellant. 2. An acquired psychiatric disorder, diagnosed as an anxiety disorder, was not shown in service and is not causally or etiologically related to service. CONCLUSION OF LAW An acquired psychiatric disorder was not incurred in service. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a procedural matter, the Board has previously remanded the claim on four separate occasions - June 2018, February 2020, April 2021, and August 2021. The claim is again before the Board and is now ready for adjudication. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Turning to the medical evidence, a November 2012 VA examiner found that the Veteran did not meet the criteria for a diagnosis of posttraumatic stress disorder (PTSD) but indicated a diagnosis of dementia/Alzheimer's with delusions and severe memory problems. Next, a September 2016 VA examiner diagnosed a major neurocognitive disorder. Further clinical treatment records from November 2017 showed a diagnosis of dementia with situational anxiety. Accordingly, a psychiatric disorder was shown, and the first element of service connection has been met. As to in-service incurrence, the service treatment records (STRs) did not show persistent complaints of, treatment for, or a diagnosis of a psychiatric disorder. During an August 1960 separation examination, the Veteran reported a medical history of depression or excessive worry; however, multiple subsequent in-service examinations showed a normal clinical psychiatric evaluation and he repeatedly denied depression or excessive worry. No diagnosis was made of a psychiatric disorder during service. As such, the medical evidence does not support the in-service incurrence of a psychiatric disorder. Rather, the appellant contends that the Veteran's acquired psychiatric disorder, to include anxiety, depression, and memory loss, was related to in-service stressors during deployment to Saudi Arabia. Specifically, these stressors included incoming enemy fire and exposure to radiation and other toxins. The military personnel records support the claim that the Veteran served in Southwest Asia. As to nexus, a September 2016 VA examiner stated that there was no evidence of a chronic disability pattern related to a psychiatric disability and the disease had a clear and specific etiology and diagnosis. As such, he found it less likely than not that a psychiatric disability was related to a specific exposure event during service in Southwest Asia. In March 2020, a VA psychologist noted that the STRs contained only a sole notation of depression or excessive worry. Further, he explained that psychological literature was devoid of a link between exposure to toxins, such as those from burning oil well fumes, and memory issues/dementia. As such, the psychologist concluded it was less likely than not that a major neurocognitive disorder was caused by or a result of service. Further weighing against the claim, an April 2020 VA psychologist opined that a psychiatric disorder was not caused by or due to the claimed in-service events. Specifically, he explained that there was insufficient evidence to suggest that memory loss, depression, anxiety, or any other acquired psychiatric diagnosis was due to the reported stressors, to include exposure to incoming enemy fire, toxins, and fear of imminent death. He noted that the Veteran did not report mental health residuals after separation from service. Additionally, although the Veteran reported anxiety and depression, the April 2020 clinician indicated that there was no evidence of a medical diagnosis of anxiety or depression. Rather, he explained that Alzheimer's dementia accounted for memory loss; however, there was no indication that it was a result of service, to include as due to toxin exposure. The VA psychologist noted that while research had shown that toxin exposure was a risk factor for developing dementia, the research was correlative and did not clearly indicate cause and effect. Next, a May 2021 VA clinician opined it was less likely than not that the Veteran had an acquired psychiatric disorder, such as anxiety or depression, that had its onset during service or was due to service, to include as due to the reported stressors. First, he noted that the STRs were unremarkable for psychiatric issues. Next, he noted that the Veteran consistently denied psychiatric concerns until he was diagnosed with dementia in approximately 2012. The clinician indicated that Alzheimer's was correlated with an impairment in autobiographical and semantic memory. Thus, he found it more likely than not that the neuropsychiatric symptoms related to service were likely based on false or impaired memories. The May 2021 VA clinician also reflected that there was inadequate and insufficient evidence to determine whether an association existed between deployment to the Gulf War and neurocognitive and neurobehavioral performance. Thus, he found it less likely than not that the Veteran's neurocognitive disorder and associated neuropsychiatric symptoms, such as depression and anxiety, had its onset during service. Further, he found it less likely than not that the disorder was the result of exposure to toxins or fear of imminent death. Also weighing against the claim, an August 2021 VA psychologist found it less likely than not that the Veteran had a diagnosis of an acquired psychiatric disorder that was caused by or incurred in service, to include the reported stressors. She noted that the Veteran was diagnosed with major neurocognitive disorder and unspecified anxiety disorder prior to his death. Next, the clinician noted that the evidence did not support the claim that psychiatric symptoms were due to service. She noted that the STRs did not document the onset of an anxiety disorder. Further, she reflected that the medical records did not show a diagnosis of an anxiety disorder until November 2017, over 25 years after the last period of active service. She also noted that the diagnosis of anxiety was made in the context of severe dementia. As such, she concluded that anxiety was not due to incoming enemy fire or fear of imminent death. As to toxin exposure, the psychologist noted that the scientific literature did not establish a causal relationship between an anxiety disorder and toxins. Rather, the clinician believed that anxiety disorder was a symptom related to the behavioral disturbance associated with Alzheimer's disease dementia. Next, the August 2021 clinician noted that scientific literature has not established a causal connection between major neurocognitive disorder due to Alzheimer's disease and exposure to incoming enemy fire, toxins, or fear of imminent death. As such, she concluded there was no nexus between any mental condition and service. In addition, the August 2021 VA clinician fully considered the lay statements submitted by the appellant. First, the clinician explained that the Veteran's lay statements submitted in December 2017 were not persuasive because he did not have the cognitive capacity to understand what he was stating. Further, the clinician found that the objective medical evidence weighed against the lay statements which contended that the Veteran had been experiencing anxiety since the 1990s. Specifically, the clinician noted that the Veteran denied anxiety and depression symptoms during a November 2012 VA examination. As the evidence did not show complaints of or a diagnosis of anxiety until 2017, the VA psychologist found the preponderance of the evidence did not support the claim that anxiety had its onset in the 1990s. The VA clinician also considered the lay statements made by the appellant in October 2020 and August 2021. She noted that there was no objective evidence in the claims file which supported a diagnosis of a psychiatric disorder in the years following the Veteran's deployment to the Gulf War. The appellant contended that the Veteran never sought mental health treatment due to symptoms of anxiety and failing health; however, the clinician noted that the Veteran continued to serve on inactive duty after his 1991 deployment and was gainfully employed for 23 years. As such, the clinician found that the Veteran was able to function satisfactorily and would have been capable of seeking mental health treatment. As such, the VA clinician found that the appellant's lay statements were not persuasive as they were not supported by the evidence. In sum, the medical evidence weighs against the claim that an acquired psychiatric disorder was caused by service. Significantly, there is no contradictory medical evidence. As such, the medical evidence does not support a grant of service connection. The Board has considered the lay statements of the appellant and the Veteran that a psychiatric disorder was caused by service. They are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses. However, they are not competent to offer an opinion as to the etiology of the disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to the lay statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kokolas, 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.