Citation Nr: 21030245 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-43 042 DATE: May 18, 2021 ORDER Entitlement to service connection for an acquired psychiatric disability, to include a personality disorder, adjustment disorder, and depressive disorder is denied. FINDINGS OF FACT 1. Personality disorders are not diseases or injuries subject to compensation benefits within the meaning of applicable law. 2. The Veteran does not have an acquired psychiatric disorder, to include adjustment disorder and depressive disorder that is etiologically related to his active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include a personality disorder, adjustment disorder, and depressive disorder, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from April 1977 to April 1997. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. This matter was previously before the Board in November 2018 when it was remanded for further development. It was returned to the Board, and entitlement to service connection for an acquired psychiatric disability, to include a personality disorder, adjustment disorder, and depressive disorder was denied in a July 2019 decision. The Veteran appealed the Board's July 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2020 order, the Court granted an April 2020 Joint Motion for Remand (JMR), vacated the Board decision, and remanded the appeal to the Board for action consistent with the JMR. In August 2020, the Board remanded the Veteran's claim for additional development. The Veteran contends that she has an acquired psychiatric disorder which began during service. She stated in her April 2016 notice of disagreement (NOD) that she served ten years before she had any problems with her mental health and the problems have persisted since service. An April 1982 service treatment record (STR) notes that the Veteran's medical records were reviewed, and they revealed no psychiatric problems. In a June 1986 medical note, the Veteran's mental health was evaluated, but no psychiatric diagnosis was noted. A March 1988 STR indicates that the Veteran was diagnosed with adjustment disorder and personality disorder not otherwise specified. The Veteran's symptoms were noted as manifested by chronic marital problems and personality traits that predisposed her to her present state of emotional lability, withdrawal, and passive-aggressive behavior with depressive features. A June 1988 STR also contains a diagnosis of adjustment disorder with mixed emotions, and a personality disorder not otherwise specified. In January 1990 and 1991, STRs note diagnoses of adjustment disorder with marital problems. An April 1994 STR notes a prescription for Zoloft. A September 1994 STR noted that the Veteran's adjustment disorder had been resolved. A September 1996 separation examination revealed no complaints, symptoms, or treatment for a mental health condition. In a January 2005 VA medical record, the Veteran was diagnosed with depression. The examiner noted that the Veteran stated that she experiences depression during the holidays and that the Veteran reported her depression may be related to her mother's suicide attempts. VA medical records from 2006 and 2007 indicate symptoms of depression, but they also indicate that the Veteran was not in mental health treatment for depression at the time. An August 2011 VA medical record notes that the Veteran had depression, bipolar disorder, and psychotic disorder, and posttraumatic stress disorder (PTSD). However, it is not clear upon what basis this note rests, and no rationale is stated. In a February 2016 VA examination, the Veteran was diagnosed with other specified personality disorder. The examiner opined that the Veteran has Cluster C traits and any adjustment issues noted in the past while on active duty are viewed as resolved at present but are at least as likely as not secondary to her personality disorder diagnosis. The examiner noted that the Veteran's VA e-folder was reviewed, and an extensive mental health history was noted. In an August 2016 substantive appeal, the Veteran stated that she did not have mental health problems prior to service and did not have mental health problems for the first seven or eight years after entrance into service. She stated that began having mental health problems during service and they have continued since service. The Veteran stated that she has personality issues that are mixed with depression and loneliness. A June 2017 VA medical record indicates a diagnosis of adjustment disorder with mixed emotional response. However, no rationale was noted as to the diagnosis, and the etiology was not indicated. An August 2017 VA medical record indicates a diagnosis of persistent depressive disorder. However, no rationale was noted as to the diagnosis, and the etiology was not indicated. In a February 2019 VA examination, the Veteran was diagnosed with other specified personality disorder. The examiner noted that a review of the Veteran's e-folder had been completed and a detailed medical history was provided. The examiner noted that the Veteran's personality disorder was acquired prior to military service. The examiner's rationale was that the Veteran does not meet DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) diagnostic criteria for a psychiatric disorder other than personality disorder at this time. He stated that is not possible to diagnose psychiatric disorders that have been resolved, and that it is possible that resolved disorders may be evident in the Veteran's medical record. The examiner opined that it is less likely than not that the Veteran's personality disorder had its onset in-service or is otherwise etiologically related to her active service. The examiner's rationale was that according to the DSM-5, the definition of a personality disorder is an enduring pattern of thinking, feeling and behaving which is stable over time and which can be traced back to adolescence or early adulthood. Further, these traits are distinct from more transient mental states or disorders. He stated that the Veteran's claim that she served for nearly a decade without a mental health diagnosis does not support the Veteran's claim that she has developed a superimposed illness during service; in fact, the examiner stated that the Veteran's claim that she served for a decade without a diagnosis would seem to contradict her claim of developing a superimposed illness during service. The examiner noted that the Veteran's in-service psychiatric evaluation in January 1991 noted that there was no evidence of an acute psychiatric disorder, yet various personality traits were indicated. The examiner added that there is ample evidence of the Veteran having lifelong difficulties with her social functioning. The April 2020 JMR agreed that a February 2019 VA opinion which provided much of the bases for the Board's July 2019 denial, was inadequate. The parties agreed that the opinion was inadequate insofar as the examiner provided no explanation as to why it was not possible to diagnose psychiatric disorders that have resolved. During a VA examination in January 2021, the Veteran was diagnosed with other specified personality disorder. The examiner commented that the Veteran displayed an enduring pattern of thoughts and feelings which lead to impairment in her social functioning. Her thoughts are typically focused on how she has been blamed or mistreated by others resulting in her chronically feeling victimized by family and co-workers. The examiner stated that the Veteran's difficulties are not due to another mental disorder, including adjustment disorder or depressive disorder and she does not meet the full diagnostic criteria for other listed personality disorders. The examiner opined that the Veteran's personality disorder was less likely than not incurred in or caused by service. The examiner's rationale was that the Veteran's personality disorder was in evidence prior to her military service. The examiner was requested to address the February 2019 VA examination report which found that it was not possible to diagnose psychiatric disorders that have resolved. The examiner stated that it is not possible to diagnose a psychiatric disorder that has been resolved because once the symptoms are resolved the individual would no longer meet the diagnostic criteria for the disorder. The examiner further opined that the adjustment disorder and persistent depressive disorder diagnoses were less likely than not incurred or due to active service. The examiner provided a detailed rationale and explained that an adjustment disorder is the development of emotional or behavioral symptoms within three months of an identified stressor, and the symptoms do not persist beyond six months from when the stressor or its consequences have terminated. Adjustment disorders are typically limited in time, but the DSM-5 allows for a chronic adjustment disorder when the stressor persists such as chronic medical conditions or prolonged unemployment. The examiner noted that the Veteran had a diagnosis of adjustment disorder in service in 1990 due to work-related problems. The examiner stated that given the military work-related stressors noted more than three decades ago during service and the fact that the Veteran is long removed from those stressors, the diagnosis of adjustment disorder which was likely accurate at the time would no longer apply. Further, the Veteran was diagnosed with an adjustment disorder by VA in June 2017 with no specific stressor identified but there was reference to the Veteran feeling depressed, her work situations at the post office, and little contact with family members. The examiner indicted that the Veteran's depression appears to have been viewed as a symptom of her adjustment disorder rather than a separate diagnosis and the adjustment disorder identified in 2017 was not a continuation of adjustment disorder in 1990. In regard to persistent depressive disorder, it is clear that the Veteran has reported mood symptoms on several occasions over the years. However, in looking at her mood disturbances, it is necessary to look at her distress at the time. The examiner indicated that it is his opinion that the source of the Veteran's distress are her behaviors and thinking patterns which make up her personality disorder. The examiner was also requested to address whether the diagnoses of adjustment disorder and depressive disorder were inaccurate or incorrect. The examiner stated that it is important to note that the DMS sets criteria and provides guidance for mental disorders diagnoses, yet there can still be subjectivity and differences in professional opinions. Additionally, diagnoses are rendered with the information on hand at the time of the encounter. The examiner noted that in this case, the Veteran has been seen by multiple providers over a span of thirty years and records indicate that she was often seen by a single provider on a single occasion for some event in her life. The examiner explained that when seen for just a single contact, it is easy to understand how a provider may not have had the opportunity to view the entirety of the Veteran's history, which is filled with conflict. In this regard, the Veteran reported significant conflict prior to service, during service, and since service. The examiner noted that when a mental health provider looks at a single event, a mental health provider could diagnose an adjustment disorder or persistent depressive disorder when the Veteran was in the middle of one of her life events. The examiner stated that the pattern can be seen only when one looks at the lifelong pattern of problems the Veteran has experienced with multiple individuals in multiple settings. The examiner noted that there is virtually no conflict-free area in the Veteran's life and her history shows an enduring pattern of behaviors and thinking which had its onset in her formative years and has led to distress or impairment. The examiner concluded that while the Veteran has experienced multiple periods of distress over the years, the Veteran's distress is the result of her personality disorder which is characterized by her chronic belief that she is being mistreated and has been victimized. In this case, although the Veteran was given a diagnosis of a personality disorder during service and has a current diagnosis of a personality disorder, personality disorders are not diseases or injuries within the meaning of applicable legislation providing VA compensation benefits. 38 C.F.R. §§ 3.303(c), 4.9, 4.127 (2020). As such, service connection cannot be attached to such a diagnosis. With regards to the to the other psychiatric disabilities, the Board finds that the most probative evidence weighs against the claim. Here, the Veteran was treated for adjustment disorder during service, however, the diagnosis was noted to be resolved in September 1994 and no psychiatric disorder was diagnosed upon separation examination in September 1996. The January 2021 VA examiner also opined that the Veteran's diagnosis of adjustment disorder during service which was likely accurate at the time would no longer apply as an adjustment disorder is the development of emotional or behavioral symptoms within three months of an identified stressor, and the symptoms do not persist beyond six months from when the stressor or its consequences have terminated and the Veteran is long removed from her in-service stressors. The examiner provided a detailed rationale for the conclusion that although the Veteran has been diagnosed with various psychiatric disabilities since service, a review of the Veteran's entire medical history makes it more likely than not that her current psychiatric symptoms are related to her diagnosed personality disorder. The Board finds both the most recent VA opinion to be higher probative, as it is based on, and corroborated by, the underlying medical evidence, and supported by a sufficiently comprehensive rationale. As there is no medical opinion to the contrary, the such opinion is considered dispositive of the claims for service connection. The Board acknowledges the Veteran's belief that her psychiatric problems are related to her service; however, the question of causation is a medically complex question and, as such, the Veteran is not competent to address etiology in the present case. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). (Continued on the next page) In sum, the Board finds that the preponderance of the competent medical evidence does not support the existence of an acquired psychiatric disorder that is etiologically related to service. Therefore, the benefit-of-the-doubt doctrine does not apply, and service connection is denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Cryan, 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.