Citation Nr: 21029861 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 20-22 484 DATE: May 17, 2021 ORDER Entitlement to service connection of an acquired psychiatric disability, other than posttraumatic stress disorder (PTSD), diagnosed as adjustment disorder is denied. Entitlement to service connection of acid reflux is denied. FINDINGS OF FACT 1. The Veteran's adjustment disorder, now resolved, did not have onset during or within one year of separation from active service; it is less likely than not related to any incident of active service. 2. The Veteran's acid reflux did not have onset during active service; it is less likely than not related to any incident of active service. CONCLUSIONS OF LAW 1. The criteria for service connection for adjustment disorder, not otherwise specified, are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for acid reflux 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 June 2005 to October 2005, from October 2005 to February 2007, from May 2007 to June 2008, and from May 2009 to May 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January and May 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal comes before the Board subject to the Legacy system of appeals. It is noted that the claims file indicates the Veteran has filed multiple appeals to the Board via VA Form 10182 with regard to multiple issues addressed in October and December 2020 rating decisions, requesting direct review of those decisions. To the extent that those appeals are subject to the Modernized system of appeals under the Appeals Modernization Act, they will be addressed by the Board in a later decision, if they are deemed properly appealed. As a matter of procedural background, this appeal previously came before the Board in December 2020, and again in March 2021, at which time the claims were remanded for further appellate review. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. 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). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including psychoses, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. 1. Entitlement to service connection of an acquired psychiatric disability, other than posttraumatic stress disorder (PTSD), diagnosed as adjustment disorder The Veteran seeks service connection of an acquired psychiatric disability, diagnosed as an adjustment disorder. The Board finds that the claim should be denied. As an initial matter, the Veteran's claim initially requested service connection of PTSD. During the pendency of the appeal, the Veteran was afforded several psychiatric evaluations which declined to diagnose that disability. He was, however, diagnosed with an adjustment disorder which was present during portions of the early appeal, later resolved. As the Board addressed in its December 2020 decision and remand, a claim of service connection of PTSD includes a claim of any other psychiatric disability which may account for the claimed symptoms. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Therefore, in the December 2020 decision, the Board denied service connection of PTSD as no present diagnosis was found, but remanded the remainder of the appeal for a non-PTSD psychiatric disability, namely, an adjustment disorder which was noted early in the appeal period. A review of the Veteran's service treatment records do not reveal any treatment for a psychiatric disability or symptoms during service. Nonetheless, there is evidence in his personnel records that he participated in combat-like operations, and therefore, there is some presumption that he suffered an in-service psychiatric stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). Next, the evidence of record does not indicate that the Veteran experienced psychiatric symptoms until May 2014, where he initially presented for a psychiatric evaluation at a VA facility, at the behest of his wife who was concerned about his irritability. At the time, he discussed conflict with his wife and also his father who had been absent for some time. He denied any past psychiatric issues. After a thorough interview with the Veteran, the VA treating provider stated that he did not meet the criteria for PTSD because, although he did describe some traumatic situations during service, he did not consider them unusual traumas which cause him clinically significant problems. Rather the examiner gave a diagnosis of adjustment disorder, not otherwise specified, and attributed that condition to post-service personal relationship issues with his wife and father. However, this first indication of a psychiatric disorder is four years after the Veteran left active duty. Moreover, to the extent that the he may assert that he did in fact experience symptoms since service, this is contradicted by VA treatment notes from 2010, which specifically noted the absence of psychiatric symptoms at that time. Therefore, service connection is not warranted based on continuity. Moreover, the evidence does not otherwise indicate that the Veteran's psychiatric symptoms are related to service. In this regard, he was afforded VA examination in June 2020, in connection with his claim. At that time, the examiner again ruled out PTSD as a diagnosis. After a complete examination of the Veteran, and a review of the complete claims file, the examiner noted the 2014 diagnosis of an adjustment disorder, and concluded that the condition had resolved. Because the Veteran's condition was considered resolved at that time, the examiner did not provide an etiology opinion for the adjustment disorder. In December 2020, a new examination was conducted via telehealth. The examiner interviewed the Veteran and reviewed the complete claims file. The Veteran denied any changes to his background information. The examiner continued to find that the Veteran did not have a presently diagnosed psychiatric disability. When questioned about his mental health at the time of the 2014 mental health visit, the Veteran reported that his anxiety and irritable mood resolved following resolution of his contemporary stressors, namely his marital issues and the contact with his father. The examiner state that the diagnosis of adjustment disorder, not otherwise specified, is considered accurate and related to those stressors as the symptoms resolved with the resolution of the stressors. If the Veteran's adjustment disorder had been related to active service, it would not have resolved as it did, and would have continued beyond that period of time. Also in December 2020, the Veteran submitted a statement from a private licensed professional counselor indicating that the Veteran identified 16 of 17 symptoms on the Military PTSD checklist administered on December 3, 2020. He also reported symptoms of widespread pain. He reported constant worry about health and the future, as well as anger, irritableness, frustration, guilt, withdrawal, isolation, sadness, and avoidance behavior. The private counselor concluded that all the psychological symptoms are consistent with the Diagnostic and Statistical Manual of Mental Disorder, 5th Edition (DSM-V) for anxiety disorder, major depression, PTSD, adjustment disorder, and insomnia due to health-related problems. No specific etiology opinion was given for those diagnoses. In March 2021, an addendum VA opinion was obtained. That opinion concluded that the claimed adjustment disorder, which was diagnosed in 2014 and subsequently resolved, was less likely than not related to any in-service incident, event or injury. The examiner supported this conclusion by stating that the Veteran was not diagnosed with any mental disorder in December 2020. Although he had a reported history of adjustment disorder, those were related to personal relationships after he returned from deployment. The adjustment disorder was resolved with divorce from his wife and curtailing contact with his father. The Board finds the VA examinations and opinions to be persuasive in this matter. They were given by psychiatric/psychological specialists in contemplation of the complete medical record, to include the Veteran's own reports of symptomatic history and treatment records. They applied known medical principles to the specific facts of this case, finding that the Veteran does not have a present psychiatric disability, and his adjustment disorder which existed for a portion of the appeal period in 2014 was not related to service, but rather due to post-service aggravating factors such as his family and marriage. The Board does recognize the December 2020 private opinion regarding diagnoses, but finds it of limited probative value. While it was given by a counseling professional, it merely lists reported symptoms and diagnoses, but does not provide a detailed explanation of how those diagnoses were given. It does not include an examination report, and despite reporting significant symptoms, it is in complete opposition to the findings of the June and December 2020 VA examinations which included in-person examinations of the Veteran where he explicitly denied any such symptomatology. Given this significant deviation from the established medical record, and the lack of supporting evidence such as an examination report, the Board finds it of limited probative value in assessing this claim. Further, the Board notes that that statement does not provide any type of etiology opinion for the Veteran's adjustment disorder. The Board recognizes the Veteran's own assertion that his psychiatric symptoms are related to service, but finds this of limited probative value as well. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his adjustment disorder, especially in light of the VA examiners' conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of any psychiatric disability or symptoms in service. See id. In sum, the Board finds that the Veteran's adjustment disorder, which was diagnosed in 2014 and has since resolved, was less likely than not related to any incident of active service; it did not have onset during or within the presumptive one year period following separation. As such, the claim for an acquired psychiatric disability other than PTSD, diagnosed as adjustment disorder not otherwise specified is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 2. Entitlement to service connection of acid reflux The Veteran seeks service connection of acid reflux. The Board finds that the claim should be denied. As an initial matter, the Board recognizes a diagnosis of acid reflux. The Veteran has claimed his condition began during service, noting that he had never been treated for the condition, and rather just dealt with it. He also asserted that his condition was secondary to his claimed psychiatric issues. As an initial matter, the service treatment records do not indicate the presence of acid reflux since service until the time he filed his claim for benefits in 2015. Indeed, the Veteran has not made any specific statements that indicate that this disorder has persisted since service. Therefore, there is insufficient evidence to conclude that service connection is warranted based on continuous symptoms. Moreover, the evidence otherwise does not indicate that the Veteran's acid reflux is otherwise related to active duty or to a service connected disability. Specifically, in December 2020, the Veteran was afforded a telephone interview to supplement his medical records. The examiner concluded that the reflux disorder was less likely than not caused by any in-service incident, illness or injury. In support of this, the examiner stated that there is no objective evidence or related complaints or treatments in the record during service. There is also no evidence of specific exposures in the record which are established etiologies of acid reflux. To the extent that the Veteran's acid reflux preexisted service, the examiner found no evidence of aggravation, noting current symptoms consisted of intermittent indigestion, nausea, regurgitation and vomiting which did not necessitate medication fall within the projected natural history of the condition and do not represent any evidence of aggravation beyond natural progression. Finally, the examiner found that the condition was likely due to his adjustment disorder, stating that mental health conditions such as adjustment disorder represent an established etiology of gastroesophageal reflux disease in the medical literature, and there are no more likely alternative etiologies for the Veteran's condition. The Board finds this opinion persuasive. It was given by a medical specialist in contemplation of the complete medical record, to include an interview with the Veteran. It applied the facts of the case to known medical principles and cited to medical treatise evidence. It included a detailed explanation for the conclusions reached. Further, the Board has reviewed the claims file but finds no medical evidence or opinions to contradict this opinion. The Board does recognize that the Veteran is competent to report observable symptoms of acid reflux during service, once the basic competency is met, the Board must consider the credibility of the statements. In the present matter, the evidence does not support that the Veteran ever sought treatment for such a condition in service, even though he sought treatment for many other issues throughout. Indeed, the evidence does not show any symptoms of his condition until several years after separation. Even presuming the Veteran did have a credible episode of acid reflux during service, the lack of subsequent treatment weighs against it being chronic in nature. To the extent that his assertions are not supported by the medical record, and given the timing of the assertions and the Veteran's own self-interest in them, the Board does not find them credible for purposes of establishing service connection of acid reflux. See Caluza v. Brown, 7 Vet. App. 498 (1995). As such, a continuity of symptoms from the time of service is not established. The Board further acknowledges the Veteran's own opinion that his reflux disease is due to active service but finds it of limited probative value in assessing the claim. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his acid reflux, especially in light of the VA examiner's conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of acid reflux in service. See id. Finally, the Board recognizes the VA medical opinion which attributed the Veteran's acid reflux to his adjustment disorder. To the extent that the Board has denied service connection of that disability, secondary service connection of acid reflux is not supported. In sum, the Board finds that the Veteran's acid reflux is less likely than not related to any incident of active service. As such, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel