Citation Nr: 21009644 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 15-07 337 DATE: February 23, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, to include PTSD and depression, is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has had a mental health diagnosis conforming to the DSM-V criteria at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include PTSD and depression, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1967 to October 1988. This matter is on appeal to the Board of Veterans’ Appeals (Board) from a January 2014 rating decision. The claim was remanded by the Board in a June 2018 decision; the Board finds the remand directives have been complied with. Initially, the Board notes that the Veteran filed his claim for “chronic depression.” The Board has recharacterized the issues more broadly to encompass any mental health disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303 (d). There are particular requirements for establishing service connection for PTSD which must be met independently of the general requirements for service connection. See 38 C.F.R. § 3.304 (f); Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a), that is, a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders; 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). The regulation governing the establishment of service connection for PTSD was modified effective August 2014; a diagnosis of a mental health disability must now conform to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V). This modification applies to claims certified to the Board after August 4, 2014. See 79 Federal Register 45093, 45094 (August 4, 2014). Before that time, VA required a mental health diagnosis to conform to the 4th Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). As the Veteran’s case was certified to the Board in March 2015, the DSM-V applies. The Veteran’s service treatment records (STRs) show no complaints or treatment for mental health issues. Post-service treatment records show mental health-related prescriptions for treatment such as Cymbalta, Celexa, and Sertraline but do not reflect a corresponding diagnosis nor mental health treatment. A March 2019 VA treatment record notes a history of high anxiety. In February 2013, the Veteran requested a referral from his family physician to see a psychologist. He explained he thought he had PTSD. While he did not experience flashbacks of traumatic events, he did endorse becoming emotional while watching war movies. The Veteran’s treating psychologist, Dr. W, submitted a report of his evaluation of the Veteran. In his clinical interview, the Veteran reported two traumatic in-service incidents, one in which a fellow servicemember committed suicide and another in which a fellow servicemember was killed and the Veteran had to relay the news to the servicemembers’ parent. Dr. W concluded the incidents were sufficient and consistent with producing PTSD under DSM-IV. Following these incidents, the Veteran reported becoming easily stressed and having high anxiety along with chronic sleep disturbance. His spouse reported he is moody and has periods of depression. He avoids violence, military movies, and scary movies. He is easily angered and irritable. Dr. W stated that anxiety and depression combined are hallmark symptoms of PTSD, and that his symptoms and behaviors are consistent with a diagnosis of PTSD under DSM-IV. He concluded that it is just as likely as not that the Veteran suffers from PTSD triggered by the tragic death events he experienced in the Navy. Dr. W submitted an accompanying Disability Benefits Questionnaire. Along with the diagnosis of PTSD, he opined the Veteran experienced occupational and social impairment with reduced reliability and productivity. His listed symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty adapting to stressful circumstances, obsessional rituals that interfere with routine activities, and impaired impulse control. In September 2013 and March and June 2020, the Veteran was sent letters requesting more information regarding his in-service stressors that resulted in PTSD. No response was received. A VA examination was conducted in November 2020. The examiner reviewed the claims file and interviewed the Veteran and found that no mental health diagnosis was indicated. At the time of examination, the Veteran endorsed no mental health symptoms and stated he “never believed he had anxiety or depression.” He reported seeing a psychiatrist over the years but provided no additional detail. Regarding his current prescription for Sertraline, he could not recall when or why he began taking it but recalled that his wife felt he needed it. He endorsed three in-service stressors - two suicides of fellow servicemembers, and one involving the death of a servicemember where the Veteran was tasked with relaying the death to the servicemembers’ parent. However, the examiner indicated he could not recall key details of his stressors, which made corroboration challenging. Regarding the in-service stressors, the examiner found that the stressors met Criterion A, meaning they are adequate to support a diagnosis of PTSD. However, Criterion B, C, D, F, G, H, and I were not met. Regarding Criterion E, sleep disturbance was noted to be a marked alteration in arousal and reactivity associated with the traumatic event. The examiner concluded that it was less likely than not that the Veteran has a mental diagnosis that is related to service. The claims file contains no information regarding symptoms or diagnosis of mental illness during service. She stated that even if his stressors could be corroborated, his symptoms are not consistent with PTSD nor any other mental health disorder. She noted that following service, the Veteran was placed on an anti-depressant, but he did not recall why and was uncertain if the medication provided any form of benefit to him. The examiner stated that the information in Dr. W’s 2013 report is inconsistent with the findings in the current examination as the Veteran did not report the symptoms reported in 2013. The evidence is insufficient to support a mental health diagnosis under DSM-V criteria. The Board finds the November 2020 examination to be highly probative, as it is based on a thorough review of the record and interview with the Veteran and it provides a clear rationale for the conclusion. While the Board acknowledges the history of anti-depressants, the treatment records provide no diagnosis or any further information as to the reason he is prescribed such medication. The Board also acknowledges the Veteran’s statements in the record that he has a history of anxiety and that he believed he had PTSD; however, while the Veteran is competent to testify as to his symptomatology, there is no evidence in the record to suggest he is competent to provide a diagnosis in these circumstances. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide a medical diagnosis). While Dr. W’s report indicated the Veteran suffers from several symptoms of mental illness, not only is there no objective evidence of these symptoms elsewhere in the record but they are directly contradictory with the findings of the November 2020 examination, to include the Veteran’s own testimony. Regardless, as the diagnosis does not conform to the DSM-V criteria, the Board must afford Dr. W’s opinion less weight. In sum, the preponderance of the evidence weighs against a finding of a mental health diagnosis and the Veteran’s claim must be denied. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Carroll, 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.