Citation Nr: 21029557 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-12 158 DATE: May 13, 2021 ORDER Entitlement to service connection for a skin disorder, claimed as due to exposure to contaminated water at Camp Lejeune, is denied. Entitlement to service connection for neurobehavioral effects, claimed as due to exposure to contaminated water at Camp Lejeune, is denied. REMANDED Entitlement to service connection for PTSD is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a skin disorder began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that neurobehavioral effects 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 a skin disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for neurobehavioral effects have not been 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 had active service from December 1972 to January 1978. The matter comes before the Board of Veterans' Appeal (Board) on appeal from a July 2014 rating decision of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In May 2019, the Board remanded the issues on appeal to the AOJ, and it now returns to the Board for appellate review. With respect to the characterization of the claims for service connection for a skin disorder and an acquired psychiatric disorder, the Board notes that a September 2012 rating decision denied service connection for an acquired psychiatric disorder, characterized as PTSD, and a skin rash, and a December 2013 rating decision determined that new and material evidence had not been received in order to reopen such claims. However, as new and material evidence addressing the bases of such denials was received within one year of the issuance of each decision, the Board finds that the instant matters stem from the Veteran's original claims for service connection for such disorders received in October 2010 and January 2011, respectively. 38 C.F.R. § 3.156(b). The Board also notes that, following the issuance of a statement of the case (SOC) in August 2015, the Veteran perfected an appeal as to the issue of whether VA was correct to stop and reduce pension benefits due to Social Security Administration income in September 2015. A review of the Veterans Appeals Control and Locator System (VACOLS) reveals that the AOJ appears to have closed such appeal in error. However, as such issue has not been certified for appeal, and as the Veteran has requested a Board hearing in connection with it, the Board will not accept jurisdiction over it at this time. Initially, the Board notes that exposure to contaminated water at Camp Lejeune has been acknowledged in this case, as the Veteran's service records confirm his service at Camp Lejeune for more than thirty days during the relevant period. See 82 Fed. Reg. 4173, 4173-4185 (Final Rule, eff. Mar. 14, 2017). However, his claimed disabilities are not among the diseases for which presumptive service connection based on exposure to contaminated water at Camp Lejeune may be granted. See Diseases Associated with Exposure to Contaminants in the Water Supply at Camp Lejeune, 82 Fed. Reg. 4,173 (Jan. 13, 2017) (listing the diseases determined to be associated with exposure to contaminated water at Camp Lejeune: kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer). Notwithstanding this, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). 1. Entitlement to service connection for a skin disorder, claimed as due to exposure to contaminated water at Camp Lejeune; and entitlement to service connection for neurobehavioral effects, claimed as due to exposure to contaminated water at Camp Lejeune The Veteran contends that his skin disorder and neurobehavioral effects are related to his exposure to contaminated water at Camp Lejeune when he was stationed there from April 4, 1973, to June 19, 1973. 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). 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. The Board concludes that while the Veteran has been diagnosed with dermatitis, psychosis NOS, PTSD, anxiety, illicit drug and alcohol abuse, personality disorder, the weight of the evidence is against finding that these began during service or are otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was not diagnosed with dermatitis until February 2010, psychosis NOS in June 2007, and adjustment disorder in April 2003, decades after his separation from service. A VA psychiatry note indicated that the Veteran had suicidal thoughts and hallucinations. He was in the process of divorce and was dealing with his mother's death. He was diagnosed with adjustment disorder, second to problems relating to primary support (in process of divorce, grieving over death of mother), problems related to social environment (very few friends), and economic problems. A March 2005 VA primary care treatment note indicated a positive PTSD screen. During a June 2007 VA physical examination, the Veteran stated that he saw people behind him that scratched him. He was diagnosed with psychosis NOS and rule out PTSD. He reported being treated for anxiety with medications for 4-5 years. He was having visual and auditory hallucinations. He had suicidal thoughts the previous evening. The Veteran was treated for a pink rash on his back and left arm in December 2009. He was treated with antibiotic cream and rubbing alcohol. During a February 2010 VA dermatology appointment, the Veteran complained of a rash on his back and left arm that had been itchy for 2 months. He was diagnosed with dermatitis, etiology unknown. He was prescribed a topical cream. He was to schedule a follow-up if his dermatitis flared. In January 2020, a VA examiner opined that the claimed skin disorder and neurobehavioral effects were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Veteran was stationed at Camp Lejeune from April 4, 1973, to June 19, 1973, approximately 76 days. The Veteran's first positive screen for PTSD occurred in 2005. He has had several psychiatric hospital admissions for a constellation of psychiatric diagnoses, including PTSD, anxiety, paranoid delusions, visual hallucinations, auditory hallucinations, and psychosis NOS. In an October 2013 statement, the Veteran asserted that his PTSD symptoms are the result of exposure to deceased bodies returning from the Vietnam War. He also complained of a persistent rash on his back and left arm. Medical records from 2009 to 2010 document his concern for the rash. He was treated with topical ointments, topical antibiotics, and rubbing alcohol. These treatments appeared to work; however, the rash returned, and the Veteran needed to continue treatment. In February 2010, the Veteran was diagnosed with dermatitis by a VA dermatologist and was prescribed a steroid cream. A follow-up appointment was not scheduled, and his October 2010 physical examination did not identify a skin rash, nor did the Veteran complain of such. Multiple treatment visits since 2010 have not noted the persistence of a rash. The Veteran has a past medical history significant for personality disorder, anxiety, COPD, type 2 diabetes mellitus, hypertension, substance abuse (alcohol, cocaine, marijuana), as well as PTSD and psychotic disorders. He has chronic back and shoulder pain. He is a 1-2 pack per a day smoker for over 30 years. He worked on an assembly line for 17 years prior to retiring. The product being assembled was not identified. He has a family medical history significant for cancer, emphysema, schizophrenia, and a sister who had at least one suicide attempt. The examiner reviewed the Assessment of Evidence for Drinking Water Contaminants at Camp Lejeune and Specific Cancers and Other Diseases, as well as the general medical literature, and found that no association was identified between exposure to chemicals in the Camp Lejeune drinking water and later development of neurobehavioral effects or a skin disorder/rash. As such neither neurobehavioral effects nor skin disorder/rash are listed as one of the presumed service-related conditions stipulated by the VA for service members stationed at Camp Lejeune. The examiner concluded that the Veteran's neurobehavioral effects and skin disorder/rash were not caused by or the result of his exposure to the contaminated water at Camp Lejeune. The examiner found that the Veteran was exposed to much lower levels for a much shorter period of time than the workers in whom no association between those chemicals and neurobehavioral effects or a skin disorder/rash was identified. The Veteran's exposure lasted approximately 76 days and occurred approximately 40 years prior to developing neurobehavioral effects or a skin disorder/rash. The Veteran reported that his PTSD, and associated symptoms, stemmed from an incident prior to being stationed at Camp Lejeune. There is no medical evidence that exposure to any contaminant increases one's likelihood for developing PTSD. Also, according to the medical records, the Veteran has had no rash on examination or by systemic complaint after 2011 on numerous subsequent medical clinic encounters and admissions. The examiner found that it is not medically reasonable to postulate that a rash can be caused by an exposure that occurred over 30 years prior to the onset of the rash. In May 2020, a VA examiner opined that the claimed neurobehavioral effects are not caused by or a result of the Veteran's exposure to contaminated water at Camp Lejeune. The examiner reviewed the Veteran's file and found that he had been diagnosed with PTSD, psychosis NOS, illicit drug and alcohol abuse, and personality disorder. The examiner reviewed the Assessment of Evidence for Drinking Water Contaminants at Camp Lejeune and Specific Cancers and Other Diseases, as well as the general medical literature, and found that there are no studies cited which link PTSD, psychosis NOS, illicit drug and alcohol abuse, and personality disorder as a sequelae to exposure to water contaminants at Camp Lejeune. Medical literature notes that factors associated with a higher risk of developing PTSD includes experiencing a combat role in war, childhood adversity, and a serious accident. The VA examiner's opinions are probative, because they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). During his March 2021 Board hearing, the Veteran testified that he served at Camp Lejeune, North Carolina, from April 1973 to June 1973. The Veteran's wife noted that during the past seven years he was irritable, had slow thinking, difficulty holding objects, and would come in and out of consciousness occasionally. Also, the Veteran's wife noted that the Veteran had blisters on his back that would come and go. The Veteran stated that he noticed the blisters after being discharged from active service; however, he did not note which year and his wife only knew that it was prior to their marriage in 2005. The Veteran believes his skin rash and neurobehavioral effects are secondary to drinking water contaminants that he was exposed to at Camp Lejeune. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiner's opinions. The most probative evidence is against finding that the Veteran's skin disorder and neurobehavioral effects are related to any qualifying period of service. Service connection is not warranted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. REASONS FOR REMAND 2. Entitlement to service connection for PTSD remanded. Unfortunately, due to reasons that follow, an additional remand is required. Although the Board sincerely regrets this additional delay, it is necessary to ensure the Veteran is afforded adequate due process and every possible consideration. The Veteran contends that he is entitled to service connection for PTSD due to his active military service. In April 2014, he reported retrieving dead bodies during the Vietnam War and that it caused PTSD and residual nightmares since. A November 1974 Report of Medical History indicated that the Veteran experienced frequent trouble sleeping, as well as depression and excessive worry. Medical treatment records note that the Veteran has been diagnosed with psychosis NOS, PTSD, anxiety, and personality disorder. Also, the Veteran has been treated for depression since establishing care with VA in 2003. In February 2016, the Veteran underwent a VA examination for mental disorders. The Veteran was diagnosed with psychotic disorder, unspecified. The examiner noted that treatment records from 1974 indicated that the Veteran had anxiety and that it progressed over time, but that his current condition is more psychosis-like with paranoia and hallucinations. Also, there was no mention of psychosis during active service. The examiner reasoned that psychosis was observed and reported. The Board cannot make a fully-informed decision on the issue of service connection for an acquired psychiatric disorder because no VA examiner has opined whether an acquired psychiatric disorder is related to active service. Therefore, an addendum medical opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain a VA medical addendum opinion to determine the etiology of an acquired psychiatric disorder. All necessary tests should be conducted, and all clinical findings reported in detail (if an examination is needed, possibly conduct a telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner is requested to provide an opinion as to the diagnosis of all psychiatric disorders found to be present, including, if appropriate, anxiety. If any previously diagnosed psychiatric disorder is not found on examination, the examiner should address the prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current acquired psychiatric disorder had its clinical onset during active service, or if a current psychiatric disability is otherwise related to any in-service disease, injury, or event, to include the in-service report of frequent trouble sleeping as well as depression and excessive worry. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion, as well as specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Costello, 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.