Citation Nr: 21030785 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 16-41 214 DATE: May 19, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, diagnosed as major depressive disorder, recurrent, severe (with history of psychotic features), is granted. FINDING OF FACT The Veteran's acquired psychiatric disorder, diagnosed as major depressive disorder, recurrent, severe (with history of psychotic features), is at least as likely as not related to active service. CONCLUSION OF LAW The criteria to establish entitlement to service connection for an acquired psychiatric disorder, diagnosed as major depressive disorder, recurrent, severe (with history of psychotic features), have been met. 38 U.S.C. § 1101, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Army from July 1980 to July 1983. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision. Although the Veteran requested a Travel Board hearing in his August 2016 VA Form 9, he later withdrew this request in a statement received in December 2016. As such, there are no outstanding Board hearing requests. The Board notes that the June 2015 rating decision denied entitlement to service connection for posttraumatic stress disorder (PTSD) (also claimed as mental conditions). In a November 2018 decision, the Board recharacterized the issue to include any current acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board also remanded the case to the agency of original jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD. Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 247, 431 (2006). Service connection may be granted for any disease initially 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 similarly requires (1) medical evidence establishing a diagnosis of the disorder, (2) credible supporting evidence that the claimed in-service stressor occurred, and (3) a link established by medical evidence between the current symptoms and an in-service stressor. 38 C.F.R. § 3.304(f). 38 C.F.R. § 4.125(a) provides that all psychiatric diagnoses must conform to the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 38 C.F.R. § 3.304(f). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 45, 094 (August 4, 2014). VA adopted as final, without change, this interim rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). As the AOJ certified the Veteran's appeal to the Board in February 2017, the DSM-5 is applicable in the present case. There are several avenues to document an in-service stressor, other than obtaining verification from the Joint Services Records Research Center (JSRRC) or other government records repository. In cases of in-service PTSD diagnosis, combat service, or prisoner of war status, a Veteran's stressor may be verified by lay evidence. 38 C.F.R. § 3.304(f)(1), (2), (4). Lay evidence of personal assault requires appropriate corroboration, and a stressor related to Veteran's fear of hostile military or terrorist activity requires appropriate medical evidence. 38 C.F.R. § 3.304(f)(3), (5). When the Veteran's claimed stressor is not related to combat with the enemy, the Veteran's lay testimony alone is generally insufficient to establish the occurrence of said stressor. 38 C.F.R. § 3.304(f). However, special consideration must be given to claims for service connection for PTSD based on personal assault as a result of the sensitivity and difficulty in establishing proof of the assault in such claims. Patton v. West, 12 Vet. App. 272 (1999). For VA compensation purposes, personal assault refers broadly to stressor events involving harm perpetrated by a person who is not considered part of an enemy force. Examples of personal assault include assault, battery, robbery, mugging, stalking, and harassment. Medical evidence may be used to corroborate the Veteran's claimed stressor in personal assault PTSD claims. Further, the Veteran may use evidence other than the service treatment records (STRs) to corroborate an account of the stressor incident. 38 C.F.R. § 3.304(f)(5). This evidence includes, but is not limited to: medical records, police records, statements from the Veteran's family and friends, and changes in behavior, to include substance abuse, a request for a transfer to another military duty assignment, and unexplained changes in social behavior. This evidence is still subject to a credibility analysis. Menegassi v. Shinseki, 638 C.3d 1379, 1382 (Fed. Cir. 2011). The Veteran contends that he has a psychiatric disorder, to include PTSD, that is related to active service. In February 2015 and March 2015 Statements in Support of Claim for Service Connection for PTSD, the Veteran indicated that he experienced much distress during basic training that had continued to burden him since that time. He remembered being yelled out, camping in 90 below 0 degree weather, and having items stolen during his basic training and service in Germany. The Veteran indicated that these events made him so angry that he wanted to kill someone, and he began to hear voices that told him to do so during service. The Veteran explained that he never told anyone about his problem as he did not want anyone to think that he was "crazy." Although the Veteran found that he had been able to handle or control the voices when he was young, he felt the need to seek help now that he was older and perceived the voices to be stronger. This symptom mainly occurred at night, and the Veteran's wife sought help for him when he told her that the voices told him to kill her and the children he loved. In another February 2015 statement, the Veteran similarly indicated that he began to hear voices while stationed at Fort Riley. He also indicated that his aunt who raised him passed away during his service in Germany, and he suffered sadness and withdrawal as a result. The Veteran also indicated that the voices had worsened since he recently underwent a major surgery. The Board notes that the Veteran's Record of Assignments in his military personnel records confirms that his active service included a period of basic training from July 1980 to September 1980 at Fort Jackson in South Carolina, a period of service in Germany from November 1989 to July 1982, and a period of service at Fort Riley in Kansas from August 1982 to July 1983. In his June 2015 Notice of Disagreement, the Veteran indicated that he had sought to "cover up" the mental thoughts he had when he was young, but he was currently suffering now that he was older. In a July 2015 statement, the Veteran reported that all the problems he was having now started in the Army. A review of the Veteran's service treatment records (STRs) does not show any complaint, diagnosis, or treatment related to a psychiatric disorder. The June 1980 enlistment examination did not note any abnormalities in the Veteran's psychiatric functioning on clinical evaluation, and the Veteran did not report a history of any relevant problems in the June 1980 Report of Medical History. These findings and reports were unchanged in the June 1983 separation examination and Report of Medical History. The earliest available post-service treatment records show that the Veteran initially denied having certain psychiatric symptoms, including depression or having thoughts of harming himself or someone else. See January 2010 VA treatment record; January 2012 VA treatment record; August 2014 VA treatment record. In August 2014, a VA treatment record stated that the Veteran mentioned some depression, but he indicated that it was simply situational and would pass. He denied having symptoms of anxiety, loss of interest in activities of energy level, thoughts of/wishing death, or a belief that his family would be better off if he was dead. In October 2014, a private treatment record reported that the Veteran answered questions appropriately and there were no signs of depression. On January 7, 2015, a private treatment record noted that the Veteran presented with his wife who has concerned about his recent mood and behavior. He had been talking to himself for several weeks and isolating himself from family members which was unusual for him. The Veteran reported that he had been hearing voices telling him to hurt others. The assessment was mood disorder and hearing voices. On January 8, 2015, a VA treatment record noted that the Veteran had been hearing voices for several years; but he never had a mental health evaluation. The Veteran's spouse reported that her husband might need medication for depression and anger management. On January 9, 2015, a VA treatment record noted the report from the Veteran's wife that he had battled depression over the past year due to his medical condition and hospitalizations. The wife reported that he was complaining of hearing voices that instructed him to harm his family. Another January 9, 2015 VA treatment record noted that the Veteran and his wife reported that he had experienced worsening moods since his July 2013 Whipple surgery when he was in and out of the hospital until September. He also reported hearing voices when sleeping that told him to hurt himself or his family. The record stated that he never heard voices during the day except for maybe 15 to 20 years ago, but he did not remember many details. The DSM-5 diagnosis was major depression (rule out psychotic features). The Board notes that although the record referred to the Whipple surgery as being conducted in July 2013, and the assessment stated that the Veteran was status post Whipple procedure in July 2014 due to cancer. This report is consistent with other VA treatment records stating that the surgery took place in July 2014. The Veteran was afforded a VA examination related to his claim in August 2019. The examiner noted that the Veteran had a current diagnosis under the DSM-5 of major depressive disorder, recurrent, severe (with history of psychotic features). The examiner explained that although the Veteran had no current psychotic features, he had psychotic features with previous depressive episodes. Regarding the Veteran's relevant medical history, the examiner noted that the Veteran did not like being stationed in Germany while on active duty, he was more socially isolated during service, and he did not feel respected by other soldiers. The Veteran recalled that others yelled and cursed at him, and some of his items were stolen during service. He began to feel stressed and resentful of others. The examiner noted that the Veteran indicated in a lay statement that he began to hear voices in his head with thoughts of killing himself or others during service. The examiner indicated that the Veteran's aunt who was like a mother to the Veteran also died while he was on active duty. Following this event, the Veteran experienced complicated grief and a depressed mood during service. The examiner noted that this report was consistent with the Veteran's statement in an April 2015 psychiatric note. He did not experience military traumas, including military sexual traumas, or combat exposure. In addition, the Veteran did not seek mental health treatment during service. The Veteran also did not have any mental health treatment prior to service and did not report any pre-military mental health issues. The examiner opined that it was at least as likely as not that the Veteran's major depressive disorder, recurrent, severe (with history of psychotic features) was proximately incurred in or caused by routine (non-combat) in-service stressors. The examiner highlighted the Veteran's report in a lay statement that he began to hear voices in his head (with thoughts of killing himself or others) during his military service. He also had a complicated grief and depressed mood after the death of his aunt during service which was discussed during the examination and supported by a statement he made in an April 9, 2015 psychiatry note. The examiner noted that the Veteran also mentioned experiencing some situational depressed mood in an August 7, 2014 medical note. A January 8, 2015 Daymark Mental Health consultation also showed that he was diagnosed with major depressive disorder, recurrent, with psychotic features. During a subsequent psychiatric consultation on January 8, 2015, he was diagnosed with major depressive disorder and placed on a Sertraline and Trazodone prescription. He had auditory hallucinations with thoughts of harming/killing himself or others at that time; but he had no associated self-harm or assaultive behaviors. On April 9, 2015, a psychiatric consultation regarding the Veteran's continued depression and thoughts of harming others (without auditory hallucinations), and he denied any history of trauma at that point. The examiner noted that the Veteran reported that he had continued with VA outpatient mental health services, and he had a positive screen for depression during the August 2019 VA examination. The Board notes that the examiner's summary is consistent with the information in the referenced records. After considering the August 2019 VA examiner's opinion as a whole and in the context of the record, the Board finds that the examiner's conclusion provides probative value as it addresses the medical issues in this case and was based on an analysis of the evidence and current medical understanding. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (providing that an examination is not rendered inadequate where the rationale provided by an examiner did not explicitly lay out the examiner's journey from facts to a conclusion); see also Acevedo v. Shinseki, 25 Vet. App. 289, 294 (2012) (stating that medical reports must be read as a whole and in the context of the evidence of record). In addition, there is no negative opinion to weigh against the examiner's conclusion. The August 2019 VA examiner's opinion is also consistent with the Veteran's reported history that he first began to experience psychiatric symptoms during service that have continued since that time. The Board notes that the Veteran is competent to attest to observable events and symptoms that he experienced. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board also finds the Veteran's reported history to be credible. Although the Board has considered the Veteran's denials of psychiatric symptoms in the June 1983 Report of Medical History and the initial treatment records after service, the Veteran explained that he strived to hide his symptoms based on his apprehension over how others would treat him. While the January 2015 VA treatment record also noted that the Veteran experienced symptoms of hearing voices in the daytime approximately 15 to 20 years earlier, this record did not address when the Veteran first began to experience this symptom at nighttime when he has reported that he normally heard the voices. The Veteran also has consistently indicated that this symptom in addition to his symptom of depression first began during service in response to his in-service treatment and the death of his aunt that occurred at that time. Resolving all doubt in favor of the Veteran, the accepts his reported medical history as credible. Based on the foregoing, the most probative evidence supports finding that the Veteran's diagnosed major depressive disorder, recurrent, severe (with history of psychotic features) is related to his active service. In reaching this decision, the Board acknowledges that the Veteran has asserted that he has PTSD, and he was previously assessed to have mood disorder in January 2015. Notably, the August 2019 VA examiner completed a Disability Benefits Questionnaire (DBQ) specific to mental disorders (other than PTSD and eating disorders). Nevertheless, the examination report also noted that if the Veteran had a diagnosis of PTSD, then the examiner should complete the Initial PTSD Questionnaire in lieu of the mental disorders DBQ. However, the examiner did not complete the separate questionnaire to indicate that the Veteran had a PTSD diagnosis, and the examiner specifically noted in the report that the Veteran did not have more than one mental disorder diagnosed. The Board finds that the examiner's determination as to the proper diagnosis is entitled to great probative weight as the examiner based the conclusion on clinical findings and his medical expertise. The benefit sought on appeal is also granted in a manner consistent with the fact that the most probative evidence shows that the proper diagnosis for the Veteran's current psychiatric complaints is major depressive disorder, recurrent, severe (with history of psychotic features). Thus, the Board concludes that service connection for this psychiatric disorder is warranted. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.