Citation Nr: 21015703 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 14-35 493 DATE: March 18, 2021 ORDER Service connection for a psychiatric disorder, including major depressive disorder and generalized anxiety disorder, is denied. Service connection for a giant cell bone tumor of the right wrist is denied. REMANDED Entitlement to service connection for tremors is remanded. FINDINGS OF FACT 1. The Veteran’s diagnosed psychiatric disorders, including major depressive disorder and generalized anxiety disorder, are not linked to disease or injury incurred or aggravated in active service. 2. The Veteran’s giant cell bone tumor of the right wrist is not linked to disease or injury incurred or aggravated in active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder, including major depressive disorder and generalized anxiety disorder, have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for residuals of a giant cell bone tumor of the right radius have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1975 to October 1977. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matters for further development in December 2019. Service Connection Service connection generally will be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link between the current disability and the disease or injury incurred or aggravated in service (the “nexus” element). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (when the evidence supports the claim or is in relative equipoise, the claim will be granted). Psychiatric Disorder The Veteran claims service connection for a psychiatric disorder as due to exposure to aviation jet fuel during active service. See July 2009 VA Form 21-526. He has also noted that he received a hardship discharge in order to care for his mother, who was ill at the time, as his father had alcoholism and therefore was unable to provide that care. See September 2020 Correspondence; February 2020 Correspondence. For the following reasons, the Board finds that service connection is not established. The service treatment records do not show treatment or complaint of psychiatric symptoms. The October 1977 report of medical history at discharge reflects that the Veteran endorsed depression or excessive worry, and nervous trouble. The “physician’s summary” section of the form (section 25) states “concern over family situation,” presumably in reference to those symptoms. The October 1977 discharge examination report reflects a normal psychiatric clinical evaluation. The preponderance of the evidence weighs against a link between symptoms of depression or nervousness the Veteran experienced toward the end of his service associated with his early discharge due to his mother’s illness and the need to be her caretaker, and his current diagnosed psychiatric disorders. It also weighs against a link between any in-service aviation jet fuel exposure and his current psychiatric disorders. More specifically, a February 2009 VA treatment record reflects that the Veteran reported a history of being treated for depression in the early 1990’s following a divorce. A June 2009 private psychiatric examination report reflects that he related a history of experiencing depressive symptoms as a teenager, and that he was also treated for depression in the 1990’s and in 2002. The August 2010 VA examination report reflects that the Veteran stated that he was depressed before his period of active service, but felt that when he worked with aviation fuel in a pump room at the bottom of the ship, it aggravated his depression and low self-esteem. He noted that he began drinking more during and since active service. He stated that he received a hardship discharge to be the caregiver of his mother, who had a potentially terminal illness, and of his father, who only had one arm and was an alcoholic. He stated that he wished he had stayed in the service, and felt “more depressed and anxious after the military” due to having to leave to care for his parents. The August 2010 VA examiner initially observed that it was possible that exposure to aviation fuel during service could contribute to the Veteran’s psychiatric disorder, but added there was “little evidence” to support that theory other than the Veteran’s own belief that there was such a link, and his report of drinking more during service to treat the effects of his fuel exposure. The examiner ultimately found that the Veteran’s current mental health conditions are less likely than not related to service, including jet fuel exposure. Rather, they were due to factors unrelated to service, such as his severely disabling wrist condition and consequent inability to work, his loss of income, the prospect of another wrist operation, as well as early childhood abuse, resentment at having to leave the Navy to care for his parents, and going through two divorces after service. In a January 2020 statement, the Veteran wrote that he is the “child of [an] alcoholic father who abused [his] mother.” He stated that he “saw a lot of bad things and was also abused.” He stated that he worried about his mother all the time during his period of service, and noted that he felt his joining the Navy might have been a way of “escaping or running away from home.” He added that he was not happy to leave the Navy and address the challenges he faced at home. He concluded that “then and during service and after” he experienced low self-esteem, depression, and anxiety. The March 2020 VA examination report reflects that the Veteran related a pre-military history similar to what he described in the January 2020 written statement, growing up as the youngest of seven children with a father who was “heavily alcoholic and abusive” and a mother who was ill. He stated that he developed minor obsessive compulsive habits, constantly worried, had low self-esteem, and was always expecting something to go wrong. During service in the Navy, he became a specialist in jet fuel, and was proud that he excelled in school and was number one in his class. The examiner observed that the Veteran’s time in the Navy appeared to be the most productive and psychologically healthy time of his life. He was recognized for his accomplishments, and the Navy was “actually therapeutic.” However, his low self-esteem made him question whether he deserved the accolades, and he still feared failing. He also was worried about his mother’s welfare back home. When asked to return home to care for his parents, he reluctantly agreed, and was released from the Navy based on family hardship. The situation at home was the same as when he left: the father was still “severely alcoholic, neglectful, and emotionally abusive.” The Veteran became resentful of his parents and siblings for asking him to leave a good career in the Navy, and his depression worsened after returning home. The examiner noted that the depression did not worsen during the Navy, but in fact was ameliorated by his success during his service. The VA examiner provided medical opinions in an accompanying March 2020 report that essentially mirror the above discussion and respond to the questions asked in the Board’s prior remand directives. The examiner stated that the Veteran developed depression as a child and that it was not aggravated by his service but was in fact ameliorated during service. Based on the evidence reviewed above, the Board finds that to the extent that symptoms of depression or anxiety may have occurred during service when the Veteran learned that he would need to take an early discharge to care for his mother during her illness and return to the difficulties associated with his family life, such symptoms are not linked to his currently diagnosed major depressive disorder and anxiety disorder. Rather, the August 2010 and March 2020 VA medical opinions found that the Veteran’s current mental health conditions are due to factors unrelated to service, including early childhood abuse, unemployment, his severe right wrist condition, two divorces, and having to take an early discharge to be a caregiver to his parents. The March 2020 VA examiner found that the Veteran’s period of service was “actually therapeutic,” and that any pre-existing depression was ameliorated during service. As the medical opinions were rendered by medical professionals specializing in mental health, are based on review of the pertinent medical history and examination of the Veteran, and supported by thorough explanations, they constitute probative evidence. The Veteran has not submitted competent evidence supporting a link between aviation fuel exposure and his current mental health conditions. While the August 2010 VA examiner initially observed that it was possible that aviation fuel exposure contributed to the Veteran’s mental health condition, the examiner found such a relationship unlikely, citing other factors as being more likely the cause, and noting that the only basis for the fuel exposure theory was the Veteran’s own belief in that theory and his report of increased drinking during service to treat the effects of the exposure, i.e. dizziness, headaches, etc. The examiner indicated, however, that the Veteran’s history of drinking was not linked to his current symptoms. The Veteran has not submitted any evidence supporting the fuel exposure theory. As a layperson in the field of medicine, his own belief that in-service jet fuel exposure is linked to his current symptoms is not competent, as this is a complex determination that requires medical evidence, since there is no cause-and-effect relationship that can be observed through the senses alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, the Veteran’s statements on that issue are not probative. In sum, as there is no link or medical nexus between the depression and nervousness reported by the Veteran at discharge, which was attributed to his “family situation” at the time, and his current major depressive disorder and generalized anxiety disorder, or between aviation fuel exposure during service and his currently diagnosed psychiatric disorders, the criteria for service connection are not satisfied. See Holton, 557 F.3d at 1366. The Board finds that the issue of whether the Veteran had a pre-existing psychiatric disorder that was not aggravated beyond natural progression during or by active service is moot, since the probative evidence shows that his currently diagnosed major depressive disorder and anxiety disorder are not linked to any in-service symptoms or otherwise related to an incident of his active service. The record also reasonably raises the issue of whether the Veteran’s depression has been aggravated by his right wrist condition, for which he also claims service connection. See 38 C.F.R. § 3.310(b) (providing for secondary service connection of a claimed disability on the basis of aggravation by a service-connected disability). As the claim for the right wrist condition must be denied, as discussed below, service connection for major depressive disorder as secondary to the right wrist disability cannot be established as a matter of law. See id. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Right Wrist Disability The Veteran claims service connection for a right wrist disability associated with a giant cell bone tumor of the radius, for which he underwent three surgeries. He has expressed his belief that it is linked to in-service aviation fuel exposure. See March 2018 Appellant’s Brief; September 2011 Correspondence. Alternatively, he states that it is due to “blood poisoning” during service. More specifically, he states that he developed blisters on his feet, and that blue dye from the pants he was wearing got into his socks and then entered his feet through the blisters. See September 2011 Correspondence. He states that this resulted in an episode of cellulitis, which led to osteomyelitis, which in turn caused his right wrist tumor. See January 2020 Correspondence; July 2017 Correspondence; July 2012 Correspondence. For the following reasons, the Board finds that service connection for a giant cell bone tumor of the radius, or its residuals, is not established. The service treatment records do not show, and the Veteran does not state, that he developed the right wrist tumor during service. Private treatment records show that around March 2008, the Veteran developed pain in his right wrist and forearm, and was diagnosed on x-ray with a giant cell tumor of the wrist. He underwent an operation in May 2008 at a private facility, and two subsequent surgeries at VA for recurrences of the tumor. The record shows a current disability associated with the tumor and surgeries to treat it. See April 2020 VA examination report. Regarding the theory that aviation fuel exposure caused the right wrist tumor, the April 2020 VA examiner opined that it is less likely than not that the Veteran’s giant cell tumor was caused by aviation fuel exposure. The examiner explained that a giant cell tumor is a rare, non-cancerous tumor the cause of which is unknown, but may be due to Paget’s disease. The examiner stated there was no reliable studies that aviation fuel exposure is linked to cancer in humans. The Veteran has not submitted competent or probative evidence supporting a link between his giant cell tumor of the right wrist and in-service aviation fuel exposure. As there is no cause-and-effect relationship that can be perceived through lay observation alone, this is a complex determination for which medical evidence is required. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Therefore, the Veteran’s unsupported belief that such a relationship exists is not competent evidence, and therefore is not probative. With regard to the Veteran’s theory that his giant cell tumor was caused by cellulitis during service leading to osteomyelitis which in turn caused his giant cell tumor, the service treatment records show that he developed blisters on his feet in July 1975, and a few days later developed cellulitis in the left ankle. He was hospitalized due to the cellulitis for several days. Laboratory data at the time was within normal limits. He was treated with bed rest, local therapy, and oral antibiotics. Once he was asymptomatic, he was discharged to light duty for the next several days. In a July 2012 statement, the Veteran wrote that he “googled” cellulitis and “read about osteomyelitis and how the bacteria can travel to bones in another part of the body through the blood.” He stated that his cellulitis resulted in osteomyelitis “which can be identical to [a] giant cell tumor,” and that the “end result is the body tries to regrow bone over dead bone.” He added that he has cited several web sites to show how this happens. The Board finds no indication that the Veteran’s giant cell tumor of the right wrist may be linked to his in-service cellulitis of the ankle, including via osteomyelitis. The record does not show that the Veteran developed osteomyelitis. Further, he has not submitted any supporting evidence for the proposition that cellulitis of the ankle can eventuate in a giant cell tumor of the wrist. He refers to conducting Internet searches (i.e. “googled”) and citing to websites, but he has not identified any sources for the theory he advances. The April 2020 VA examiner stated that the cause of giant cell tumors is unknown. Because the issue of whether cellulitis of the ankle can eventuate in a giant cell tumor of the wrist many years later is a complex determination that cannot be made based on lay observation alone, medical evidence is required. Consequently, the Veteran’s belief that his cellulitis ultimately caused his giant cell tumor is not competent evidence, and therefore is not probative. See Jandreau, 492 F. at 1376-77. The Board finds that a VA medical opinion on the issue of whether the Veteran’s in-service ankle cellulitis may be linked to the wrist tumor is not warranted. To trigger VA’s duty to provide an examination or opinion, there must be, in pertinent part, an indication that the current disability may be related to an in-service disease, injury, or event. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); 38 C.F.R. § 3.159(c)(4). Competent evidence is not required to satisfy that standard, but a “conclusory generalized statement” is generally not sufficient. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). While the Veteran has explained why he believes such a relationship may exist, his unsupported theory, without any grounding in a plausible basis for that theory, does not satisfy the McLendon standard. By contrast, in the example cited in McLendon, “[T]he development of arthritis in a person’s knees and the fact that that person had been a paratrooper with numerous jumps ‘indicates’ that his disability ‘may be associated’ with his service” such that a VA examination or opinion would be warranted. McLendon at 83. In other words, there is a readily apparent possible relationship between multiple impacts on the knees from parachute jumps, and the subsequent development of knee arthritis, without the need for supporting evidence. That example puts the matter into perspective, and shows why the Veteran’s unsupported theory is too far afield the type of scenario that would satisfy the McLendon standard for triggering VA’s duty to obtain a medical opinion on the issue. In sum, a link between the Veteran’s giant cell tumor and an in-service disease or injury is not established; consequently, the criteria for service connection are not satisfied. See Holton, 557 F.3d at 1366. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The December 2019 Board remand instructed the RO to schedule the Veteran for an examination to determine the nature and etiology of his tremor disorder. As that has not been accomplished, the matter must be remanded again to ensure compliance with that directive. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following actions: Arrange for a VA examination to assess the nature of the Veteran’s claimed tremor condition and to determine whether it may be related to service. The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current tremor condition—if found—is related to aviation jet fuel exposure during active service. The examiner must provide a complete explanation in support of the conclusion reached. J. Rutkin Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brendan A. Evans, 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.