Citation Nr: 21010730 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 16-47 586 DATE: February 25, 2021 ORDER Service connection for posttraumatic stress disorder (PTSD) is denied. Service connection for an acquired psychiatric disorder other than PTSD is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had PTSD at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence is against finding that the Veteran has an acquired psychiatric disorder, other than PTSD, that began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for an acquired psychiatric disorder, other than PTSD, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1972 to October 1973. A Board hearing was held in December 2020. A transcript is of record. The Veteran's claim for service connection for PTSD was denied in a November 2012 rating decision. The Veteran disagreed, and the Agency of Original Jurisdiction (AOJ) readjudicated the claim in an October 2013 Statement of the Case (SOC). Additional VA treatment records were created within one year of the rating decision but were not considered in the SOC. Despite the readjudication, because the records were constructively before the AOJ and it was never determined whether the evidence was new and material, the issue remained pending, and any discussion regarding reopening of the claim is unnecessary. 38 C.F.R. § 3.156 (b); Beraud v. McDonald, 766 F.3d 1402, 1406-07 (Fed. Cir. 2014); Lang v. Wilkie, 971 F.3d 1348, 1354-55 (Fed. Cir. 2020). The medical evidence contains multiple psychiatric diagnoses. As such, the Board has recharacterized the claim on appeal to entitlement to service connection for an acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection for an Acquired Psychiatric Disorder The Veteran asserts that he is entitled to service connection for PTSD. He asserts the claimed condition is the result of an experience in February 1973 when he was assigned to greet Prisoners of War (POWs) returning from the Republic of Vietnam (Vietnam), many showed signs of having been tortured, and he claims to have seen many coffins being unloaded from planes. See, e.g., March 2010 Veteran Statement; August 2015 Veteran Statement; December 2020 Hearing Transcript, at 4. He has also asserted that other service members showed him disturbing pictures of violence committed against enemy soldiers in Vietnam. Id. Finally, during the December 2020 Board hearing, the Veteran testified that his psychiatric disorder developed after he fell from a ladder going to the cockpit of a plane, hit his head, and lost consciousness for 10 to 15 minutes. See December 2020 Hearing Transcript, at 6-7). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection for PTSD, in contract, has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The Board concludes that, while the Veteran has a diagnosis of major depressive disorder, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The Board additionally concludes that the Veteran does not have a current diagnosis of PTSD or bipolar disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A July 2010 VA examiner opined that the Veteran did not meet the threshold for a PTSD diagnosis. The examiner considered the Veteran’s reports of seeing returning POWs that had been tortured and being shown pictures of atrocities committed against enemy soldiers. But the examiner opined the stressful events fell short of the intensity and severity of a stressor expected to have a high probability of resulting in PTSD and did not meet criteria A of the diagnostic criteria. The examiner further opined that the Veteran’s symptoms did not meet the symptom threshold for a PTSD diagnosis. Instead, the examiner opined the Veteran had a diagnosis of depressive disorder with onset several years after he left active service and explained the depressive symptoms were related to non-military psychosocial stressors such as a recent heart attack, anger at VA for not bearing the expenses of his heart attack, and stress due to calls from collections agencies. Finally, the examiner opined that the Veteran’s disability was neither caused nor aggravated by his military service or any other service-connected disability. On the other hand, private care providers have reported a diagnosis of PTSD as well as bipolar disorder. In an August 2010 record, M.E., a licensed clinical professional counselor, reported the Veteran had diagnoses of bipolar disorder and PTSD. However, M.E. did not discuss the Veteran’s reported stressors or indicate how they came to the diagnosis of PTSD using the guidelines of the DSM-IV, which was the controlling diagnostic guide at the time. The only stressful incidents discussed by M.E. were the Veteran’s recent heart attack and losses associated with his health. Further, the included diagnosis of bipolar disorder is based on an inaccurate factual premise, as M.E. reported that the Veteran had been diagnosed with bipolar disorder by VA providers; however, there is no such diagnosis in the Veteran’s VA treatment records. Finally, M.E. gave no opinion relating either diagnosis to the Veteran’s active service. As it does not appear that M.E.’s diagnosis of bipolar disorder was based on an analysis of the entire relevant history and is instead based on an inaccurate factual premise, the diagnosis is afforded less probative weight. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Reonal v. Brown, 5 Vet. App. 458, 460–61 (1993). In a later October 2010 treatment plan developed by the same care provider, R.W., whose credentials were given as BA/PRS at the time, included a statement that the Veteran’s PTSD resulted from trauma during seven years of military service which included the deaths of friends and observed cruelty by both sides. But the Veteran only served one year of active duty service and was not involved in combat. And there is no indication, given his listed credentials, that R.M. has the requisite training or experience to provide a diagnosis of a complex psychological disorder or distinguish the specific etiology of a given diagnosis and the opinion is given no probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). In a February 2011 private treatment record, Dr. S.D. also reported diagnoses of PTSD and bipolar disorder. But Dr. S.D. gave no explanation as to how the Veteran met the required diagnostic criteria for PTSD. Further, Dr. S.D. stated that the Veteran’s symptoms appeared to have started shortly after witnessing the return of POWs from Vietnam and had gradually worsened over the years. However, the available treatment records do not include any reports or treatment of psychiatric symptoms until September 2009, when the Veteran reported that he had been experiencing depressive symptoms for only four years with increasing severity following a heart attack; Dr. S.D. gave no explanation for this discrepancy in his opinion and the Veteran’s treatment history. Next, Dr. S.D. stated that the Veteran had been assigned to a rapid deployment unit, which had heightened his anxiety, but the only MOS included in the Veteran’s personnel records is aircraft maintenance specialist. And, like the diagnosis given by M.E., Dr. S.D.’s diagnosis of bipolar disorder also appears to have relied only on the Veteran’s report that he had been diagnosed with the condition at a VA medical facility. As noted above, there is no such diagnosis in the Veteran’s VA treatment records. Moreover, Dr. S.D. was equivocal in his determination that the Veteran had a true diagnosis of bipolar disorder, opining that the Veteran did not have true hyperthymic periods and denied invincible moods or related binge behavior. As it appears that neither Dr. S.D.’s diagnosis nor opinion was based on an analysis of the entire relevant history and is based in part on an inaccurate factual premise, the opinion is afforded less probative weight. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Reonal v. Brown, 5 Vet. App. 458, 460–61 (1993). The Veteran was afforded a second VA examination in June 2011. The examiner reviewed Dr. S.D.’s diagnosis of PTSD and the diagnosis of bipolar disorder given by M.E. but found neither diagnosis to be supported by the medical evidence. The examiner instead opined that the Veteran’s reported stressors did not meet criterion A of the diagnostic criteria and found no evidence of bipolar disorder. Instead the examiner opined the Veteran’s primary diagnosis was depressive disorder, which first occurred in 2009, and was as a result of a heart attack. In a June 2012 letter, R.W., who’s credentials were then listed as BA, PRS, CM, stated they had been the Veteran’s rehabilitation provider and case manager for three years and asserted that the Veteran’s experiences during the Vietnam war would “definitely be a major factor in his level of depression, anxiety, anger, and distrust of the military and the government.” But there is no indication, given his listed credentials, that R.M. has the requisite training to provide a diagnosis of a complex psychological disorder or distinguish the specific etiology of a given diagnosis and the opinion is given no probative weight. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). In October 2012, a third VA examiner again opined that the Veteran did not have a diagnosis of PTSD, and instead had a diagnosis of depressive disorder in remission. At the time, the examiner could not review the Veteran’s private treatment records but determined on examination that the Veteran’s subjective symptoms were out of proportion to the objective symptoms. The examiner opined that the Veteran erroneously accepted that all his perceived abnormalities amount to PTSD and rationalized overvalued beliefs and ideas by faulty self-reasoning. The Veteran reported that a close friend was blown up in combat in Vietnam prior to his service, his college prospects were ruined by being drafted, he did not like serving and was upset by general restrictions, experienced seeing soldiers and POWs returning from Vietnam, and he was shown horrifying pictures by returning service members. However, the examiner opined that the Veteran did not suffer from significant impairment, limitation, or incapacitation of function due to the direct effects of his experiences. The examiner noted that the Veteran had an unremarkable treatment history from 1973 to 2009 and has his first mental health contact in 2009 after a heart attack. The examiner concluded that there was no persuasive evidence for a current diagnosis for PTSD and the Veteran’s claimed stressors were not enough to support a diagnosis of PTSD. In an addendum opinion, the October 2012 examiner reviewed the Veteran’s claims file and found that the Veteran’s service treatment records did not support the contentions of PTSD. The Veteran had normal psychological entrance and exit examinations and there was no evidence to support a diagnosis from October 1973 to May 2009. The examiner noted that although private treatment providers had raised the topic of PTSD, they appeared to have relied on the Veteran’s self-report. The examiner opined that neither the VA examinations or VA treatment records showed evidence of PTSD as the Veteran’s mental status examinations and cognitive examinations throughout were normal. The examiner again opined that the Veteran’s reported stressors were not clinically sufficient to support a disabling diagnosis of PTSD and the persuasive evidence instead supported a diagnosis of major depressive disorder since 2009. In sum, although the record contains private treatment records that include diagnoses of PTSD and bipolar disorder, for the reasons discussed above, the Board finds the private treatment records are not probative. Instead, the Board finds the opinions of the several VA examiners persuasive. Each VA examiner included a detailed review of the record and provided a reasoned diagnosis and opinion supported by their findings and each VA examiner determined that the Veteran did not have a diagnosis of either PTSD or bipolar disorder and instead opined that the Veteran’s only psychiatric diagnosis was major depressive disorder, which they determined was not related to the Veteran’s active duty service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the Veteran believes he has a current diagnosis of PTSD and bipolar disorder, he is not competent to provide a diagnosis in this case. And while the Veteran believes his major depressive disorder is related to his active duty service, the Board reiterates that the preponderance of the evidence weighs against findings that the diagnosis is related to his active duty service. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Finally, while the Board acknowledges the Veteran’s testimony that he hit his head after falling from a ladder while he was in-service, there is no record of any complaint, treatment, or diagnosis related to a head injury either in the Veteran’s service records or at any other point in the medical evidence, or otherwise, prior to his December 2020 testimony at the Board hearing. As such, the Board finds the Veteran’s assertion lacks credibility. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d per curiam, 78 F.3d. 604 (Fed. Cir. 1996). Therefore, while the Veteran has not been afforded a VA examination to address this theory of service-connection the Board finds that a remand for an additional VA examination is not necessary. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). The appeal must therefore be denied. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Mine 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.