Citation Nr: 21031029 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 18-48 729 DATE: May 20, 2021 ORDER Service connection for an acquired psychiatric disorder is denied. FINDINGS OF FACT 1. The Veteran served on active duty from August 1982 to August 1986 and from January to April 1991, with periods of Reserve duty. 2. A current DSM-V diagnosis of PTSD has not been shown. 3. A diagnosis of bipolar disorder or medicine-induced psychosis is not causally or etiologically related to service, and was not caused by or permanently worsened in severity by a service-connected disability. CONCLUSION OF LAW An acquired psychiatric disorder was not incurred in service, and is not proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304(f), 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran testified before the undersigned Veterans Law Judge (VLJ) in March 2021. A copy of the transcript has been associated with the record. Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). With specific regard to PTSD claims, three elements must be present: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125 (a); (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304 (f); Cohen v. Brown, 10 Vet. App. 128 (1997). At the March 2021 hearing, the Veteran testified that she had been diagnosed with medication-induced bipolar disorder which was related to sarcoidosis and PTSD. She submitted medical records which showed a diagnosis of medication-induced bipolar disorder and psychosis. Specifically, two letters from treating nurses in May 2017 showed that she had steroid-induced psychosis due to sarcoidosis treatment. Thus, a psychiatric disorder has been shown and the first element of service connection is met. As to an in-service incurrence, the Veteran does not assert, and the service treatment records (STRs) do not show, that she had any treatment for steroid or medication-induced mental health symptoms during service. In this regard, the STRs are silent as to any treatment or, or diagnosis of psychiatric complaints during service. Thus, the medical evidence does not support service connection as the second element of an in-service incurrence has not been met. In the alternative, the Veteran has suggested that there is a medical nexus between her psychiatric disorder and duties in service related to transporting very sick and wounded servicemembers as a nurse. To this end, an April 2017 VA examiner opined that it was less likely than not that the Veteran's bipolar disorder was the result of service. The examiner reasoned that there was no evidence of mental health complaint or treatment during active duty. The examiner also noted that the Veteran's self-report pertaining to the timing of manic type symptoms had been inconsistent. Specifically, the examiner reflected that some records indicated the onset of sleep disturbance, irritability with tantrums, and other behavioral disturbances beginning in childhood; however, the Veteran reported that the manic symptoms did not begin until she was started on steroids for treatment of sarcoidosis. The examiner stated that by the Veteran's self-report, she was first hospitalized with symptoms of mania in 1992 at a hospital in Georgia; however, multiple records indicated she was not hospitalized until 1994 at which time she was diagnosed with bipolar disorder. As such, the examiner reasoned, there was no convincing evidence of mania or depressive symptoms during service or within one year of separation. Finally, the examiner noted that by the Veteran's self-report she has been hospitalized for mania numerous times but only one was at a VA facility. The examiner stated that the provider's clinical impression was "factitious disorder, medication-induced mood disorder, misuse of prescription medications, and unspecified personality disorder." In this regard, while diagnoses of bipolar disorder is seen throughout the record, there is no indication that it began in, or was otherwise related, to service. Thus, the medical evidence does not support service connection based on nexus. Rather, the Veteran's main contention is that sarcoidosis is related to service, and therefore, the medication-induced psychosis or bipolar disorder should be found to be related to service. However, as explained to the Veteran at the March 2021 hearing, she is not service-connected for sarcoidosis. Instead, the claim was denied, and she is in the process of attempting to re-file for these benefits. As the claim is not currently before the Board, and service-connection for sarcoidosis has not been established, secondary service connection is not warranted. Next, with regard to PTSD, the overwhelming medical evidence weighs against the finding of a DSM-V diagnosis of PTSD. While the private and VA treatment records are replete with notations of PTSD, they are consistently noted as impressions or diagnosis by history. In this regard, there was no finding in the extensive medical record that showed a specific evaluation for PTSD in accordance with DSM-V criteria. As such, a VA examination was ordered in April 2017. The April 2017 examiner opined that the Veteran did not have a diagnosis of PTSD in accordance with the DSM-V criteria. The examiner acknowledged that the Veteran was noting some symptoms consistent with PTSD but that the full criteria were not met. Instead, the examiner noted that the stressor contributing to PTSD symptoms included both pre-military and military traumatic events, including a history of verbal, physical, and sexual abuse by the Veteran's father. The examiner noted that the Veteran's military trauma included exposure to seriously wounded servicemembers during her work as a flight nurse, and that she continued to have nightmares of running from bombs despite denying exposure to bombs in service. The examiner noted that the reports of nightmares have contributed to diagnoses of PTSD in the record by other providers. However, the examiner noted that the Veteran did not report nightmares of experiences related to her work as a flight nurse, but reported some nightmares related to her childhood abuse, and infrequent intrusive thoughts regarding saving wounded servicemembers. The examiner noted that these symptoms did not meet the criteria for PTSD and that instead, two treating VA psychiatrists diagnosed bipolar disorder and not PTSD. The examiner acknowledged a PTSD diagnosis by a third VA psychiatrist, but that the nature of the index trauma was not described. After assessing the Veteran's symptoms and stressors, the examiner noted that while she reported having horrible nightmares, they were not of military experiences, and as such, did not meet the criteria for re-experiencing. This evidence weighs against the appeal for PTSD. On the other hand, the record reflects occasional positive screenings for PTSD, as well as the Veteran's reports of such a diagnosis; however, it is clear by the evidence of record that the diagnoses were largely diagnostic impressions and/or based on history provided by the Veteran, rather than based on a clinical assessment. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. The Board may appropriately favor the opinion of one competent medical authority over another. The Board is not obligated to accept medical opinions premised on a veteran's recitation of medical history. In this regard, the April 2017 examination was adequate for evaluation purposes. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that the examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. The April 2017 examiner reviewed and thoroughly discussed all of these findings in rendering an opinion which was well-reasoned and based upon the facts of record. Therefore, greater probative weight is assigned to the April 2017 opinion. For that reason, the weight of the medical evidence does not support a clinical diagnosis of PTSD. The Board has considered the Veteran's lay statements that her disorder was caused by service. At the March 2021 hearing, she testified that there were mental health records that she had not submitted; however, she stated that she had attempted to get the records, but they were unavailable as the hospital had closed. A June 2017 memorandum reveals that she attempted to obtain these records but that they had been destroyed. Thus, a remand to obtain those records would be futile. Nonetheless, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. However, she is not competent to offer an opinion as to the etiology of her current disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to her statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Yacoub, Associate 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.