Citation Nr: 21024247 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 15-40 798 DATE: April 22, 2021 ORDER Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and depression, is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran’s acquired psychiatric disability, to include PTSD and depression, had an onset in service or is otherwise related to his military service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression, have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1980 to November 1981. The Veteran testified at a videoconference hearing before the undersigned in March 2019. This matter was before the Board in April 2019 when it was remanded for additional development. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); 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). In order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). The Board remanded the Veteran’s claim in April 2019, in part, to afford him a VA examination. The Veteran was scheduled for a VA examination in January 2020, but failed to report. While the record does not contain a copy of VA’s notice letter informing the Veteran of the date and time of the scheduled examination, the United States Court of Veterans Appeals (Court) has held that there is no requirement that this document be contained in the record for the presumption of regularity to apply. See Kyhn v. Shinseki, 23 Vet. App. 335 (2010). Moreover, the Veteran was informed of his failure to report in an April 2020 Supplemental Statement of the Case, but has not provided a reason for his absence or a request to reschedule the examination. There is no reason to believe the VA does not have the correct contact information for the Veteran. No mail has been returned as undeliverable at the address on file, which has been used since 2011. The provisions of 38 C.F.R. § 3.655 address the disposition of claims where claimants for VA benefits fail to report for scheduled examinations without good cause. Under subsection (a), examples of “good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc.” Under 38 C.F.R. § 3.655(b), when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655. A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C. § 5107(a). While VA has a duty to assist the Veteran in substantiating his claim, that duty is not a one- way street. Woods v. Gober, 14 Vet. App. 214, 224 (2000). Based on the foregoing, the Board will decide the case analyzing the existing evidence in the record. The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, to include PTSD. The Veteran contends he has various psychiatric disorders that are related to his military service, to include stressors and physical injuries sustained therein. See December 2011 Statement in Support of Claim for PTSD; March 2019 Board hearing transcript. Specifically, the Veteran has stated that he: went through physical training not knowing he was physically disabled; woke up one time with a stranger holding a knife to his throat; heard a soldier shooting a gun in a parking lot; and witnessed people being physically abused in service. He related that people at Ft. Polk were “mean” and he was punched by his sergeant while he was shaving and kneed in the back on one occasion; he did not report these incidents or seek medical treatment. Id. He states he has had psychiatric problems since service. See August 2012 mental status examination report from Dr. A. The Veteran’s DD 214 reflects that he had no foreign service during his time in the Army from October 1980 to November 1981. His military occupational specialty (MOS) was a Cavalry Scout. The Veteran’s service treatment records (STRs), including an August 1980 induction examination report, are silent as to complaints of or treatment for a psychiatric disorder. His military personnel records do not show any reduction in rank or any disciplinary actions. He received a general discharge in November 1981 for failure to maintain acceptable standards for retention. See DD Form 214. The earliest evidence of psychiatric disability are private treatment records dated in 2009. The Veteran reported a history of childhood physical abuse by his babysitter’s boyfriend and his stepfather. He reported a history of drug use since age 13, alcohol use since age 11, and psychiatric evaluation as a teen. He also reported that his head was grazed by a bullet in a drive by shooting a couple of years earlier. The diagnoses noted by the treatment provider were major depressive disorder and psychosis. A May 2010 VA treatment record notes the Veteran’s report of PTSD, anxiety, and depression. He denied any history of inpatient treatment. He reported a history of physical and emotional abuse by a babysitter and his stepfather. After examining the Veteran, the examiner diagnosed major depressive disorder, PTSD, and drug and alcohol abuse (in remission). His stressors included financial problems, unemployment, struggles with homelessness, and social isolation. In an August 2012 letter, Dr. A noted that he examined the Veteran but did not review the claims file or any medical records. The Veteran reported sustaining a severe head injury and experiencing depression as a child. He also reported that he was physically abused and emotionally neglected as a child, until he was kicked out of the house at age 17. He then served in the Army, before receiving a general discharge. He reported being yelled at in service. He also alleged that people were being killed on base, and he woke up one time with someone holding a knife to his throat. He never reported any of these incidents. Dr. A diagnosed PTSD, bipolar type schizoaffective disorder, cognitive disorder, borderline personality disorder, and substance abuse. Dr. A also stated, “I just don’t think it is possible to sift out what is causing what, his symptoms began when he was a child and continue to the present time . . .” A February 2009 Social Security Administration decision granted disability benefits. The primary diagnosis is listed as disorders of the back, and the secondary diagnosis is listed as affective/mood disorders. Again, the Board notes that this matter was remanded in 2019 in order to assist the Veteran by affording him a VA examination; however, he failed to report to this examination. None of the evidence of record shows a nexus between a current psychiatric disability and service. Inasmuch as the medical evidence currently of record provides no reasonable basis for a grant of service connection, and the Veteran has not provided supportive evidence or cooperated with VA efforts to further develop the record, the Board is unable to grant the benefits sought. As for the Veteran’s contentions that he has current psychiatric disability related to service, the Board acknowledges the Veteran is competent to report psychiatric symptoms both during and after service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). However, the Veteran is not competent as a layperson to provide a diagnosis for his symptoms or nexus opinion in this case. The issue is medically complex and requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Fletcher, Kathleen 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.