Citation Nr: 21041910 Decision Date: 07/14/21 Archive Date: 07/14/21 DOCKET NO. 15-22 018 DATE: July 14, 2021 ORDER Service connection for a psychiatric disorder to include an anxiety disorder and or posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The preponderance of the evidence shows that the Veteran does not have a current diagnosis of a psychiatric disorder as a result of any injury or disease in service. CONCLUSION OF LAW The criteria for service connection for a psychiatric disorder to include an anxiety disorder and/or PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Air Force with active duty from November 1968 to November 1972. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2013 Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for an anxiety disorder. The Veteran's notice of disagreement (NOD) was received in September 2013. The RO issued a statement of the case (SOC) in April 2015. The Veteran's VA Form 9, substantive appeal to the Board, was received in June 2015. In April 2019, the Board remanded the case to the RO for further development and adjudicative action. The Veteran contends that he has an anxiety disorder that was caused by a bomb blast that occurred in the Republic of Vietnam during service. 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 the Veteran does not have a current diagnosis of psychiatric disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this regard, the February 2013 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of worry, the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-IV criteria and he did not have a mental disorder that conforms with DSM-IV criteria. The examiner explained that the Veteran did not present with symptoms that met the DSM-IV-TR diagnostic criteria. While the Veteran reported experiencing difficulty sleeping associated with worry, these symptoms were largely experienced in isolation of other anxiety-related symptoms and were not to an extent that interfere with daily functioning. The examiner further noted that while the Veteran endorsed recent stressors that served to exacerbate low-level worry, his response to these stressors were normative and were not to a degree that had impacted functioning. The examiner concluded that no Axis I diagnosis was warranted. VA treatment records dated in October 2012, December 2014, and July 2018 document that the Veteran has a prior medical history of anxiety. However, this is not evidence of a medical DSM diagnosis; because the term "history of" means that the clinician did not provide the diagnosis. VA treatment records dated in July 2018 and June 2019 document that the impression/plan included anxiety rare Xanax as needed. While VA clinicians documented that the Veteran had anxiety, there is no indication that the clinicians performed a physical examination or any diagnostic tests to confirm the presence of anxiety or an anxiety disorder. Instead, the statement appears to be based on the Veteran's self-reported medical history. A February 2020 VA treatment record diagnosed the Veteran with unspecified trauma and stressor related disorder, rule out PTSD. A March 2020 VA mental health diagnostic study note reveals that generalized anxiety disorder assessment (GAD-7) score was 7. The VA note explained that a score of 15 or greater is considered clinically significant, meriting active treatment for anxiety and a score of 10 to 14 indicates a condition that should be carefully evaluated. A PHQ-9 Depression Scale score was 3. A total score from 1-4 is considered minimal depression. The Veteran had a PCL-5 score, which evaluates PTSD, of 17, indicating mild symptoms were reported. A March 2020 VA treatment record indicates that the diagnostic impression was PTSD, unspecified. The Veteran underwent another VA examination in August 2020. The VA examiner determined that the Veteran did not meet the diagnostic criteria for PTSD under DSM-5 criteria and there was no mental disorder diagnosis. The examiner explained that the Veteran does not meet PTSD criteria, because, although he meets Criterion-A, he does not sufficiently meet Criteria-B, C, D, E, or G. The examiner provided a thorough explanation for why the Veteran did not meet each Criteria. The examiner further noted that the Veteran repeatedly screened negative for PTSD and depression in many VA treatment records. Although his October 2012 primary care physician shows his complaint of anxiety, he also reported having just retired, thus providing a then-current life stressor that might account for the reported anxiety. VA treatment records dated in December 2014, December 2014, January 2016, June 2019, and June 2020 reveal that his psych status was "no depressions, no anxiety, no hallucinations." There are not findings in these records that the conditions for which he was prescribed the Alprazolam and Ambien were related to his in-service experiences. The examiner stated that despite the February 2020 VA treatment that diagnosed the Veteran with unspecified trauma/stress related disorder after he discussed an in-service event of watching a gunner shoot from a helicopter at people on rice paddies and his March 2020 VA treatment record that reflects unspecified PTSD diagnosis in relation to the same helicopter incident, the same note also reflects his report of his mood as "good;" and that he had only had memories or nightmares of them for a week, but that they had decreased significantly. The examiner determined that these records were outweighed by the by more consistent absence of any PTSD or any other trauma/stressor symptoms in the VA treatment records from 2012 to mid-2020 and by his March 2020 mental health diagnostic which shows PCL-5 score of 17, which is substantially below the clinical score of 33 that would require a PTSD diagnosis. Additionally, the March 2020 VA treatment record shows he was seen for individual therapy by VA video connected, during which his PTSD diagnosis was reviewed for clarification purposes. Although the provider found that the Veteran was positive for Criterion-A from having witnessed from a helicopter the shooting of individuals in a rice field and although he had intrusive symptoms, there were no avoidance symptoms; thus, the Veteran did not meet PTSD criteria. The author noted that these symptoms had only recently surfaced and might be related to the 50th anniversary of the event and to his retirement. This note then shows that no diagnosis was given, and the Veteran reported that he was not interested in therapy. The examiner concluded that consistent with current findings, the recent PTSD and trauma-/stressor-related disorder diagnoses in recent VA treatment records are shown by other records to have no bases upon further clinical scrutiny and testing. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider considers such factors as its thoroughness and degree of detail and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444 (2000). An evaluation of the probative value of a medical opinion or diagnosis is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusions reached. The Board may then determine the credibility and weight to be attached to such opinions. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). In this case, the February 2020 VA treatment record from a psychologist that diagnosed unspecified trauma and stressor related disorder rule out PTSD was based on an initial interview. Thereafter, in March 2020, a psychology intern diagnosed the Veteran with PTSD based on the results of the following tests: PHQ9 3 (minimum), GAD7 mild, and PCL5 mild. The psychology intern or psychologist did not provide any explanation for the diagnoses of unspecified trauma and stressor related disorder or PTSD or explain the connection between the results of the psychological evaluations and the diagnoses provided. The psychologist and psychology intern did not indicate that they reviewed his medical history and they did not have access to his claims file. In contrast the VA examiners in February 2013 and August 2020 provided a clear explanation for why the Veteran did not meet the criteria for PTSD or any other mental health disorder under the appropriate diagnostic criteria. The August 2020 VA examiner explained clearly why the Veteran did not meet the criteria for PTSD under DSM-5 based on the examination the examiner conducted. Furthermore, the VA examiner reconciled his medical opinion with evidence in the VA treatment. As discussed above, he explained in detail why the results of the major depressive disorder test, generalized anxiety disorder test, and PTSD test documented in the March 2020 VA treatment record did not reflect that the Veteran met the requirements for a diagnosis of PTSD or other mental health disorder. He also discussed the Veteran's documented medical history in detail based on a review of the Veteran's VA treatment records, as well as, the Veteran's claims file and how that formed his decision in determining that the Veteran did not have a current mental health disorder to include an anxiety disorder or PTSD. Accordingly, the Board finds that the medical opinions provided by the VA examiners in February 2013 and August 2020 in determining whether the Veteran had a current diagnosis of a mental health disorder under DSM-IV and DSM-5 criteria are more persuasive than the evidence provided in the February 2020 and March 2020 VA treatment records. Consequently, the Board gives more probative weight to the February 2013 and August 2020 VA examiners' findings and opinions. While the Veteran believes he has a current diagnosis of a psychiatric disorder, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent and probative medical evidence that the Veteran's symptoms does not meet the criteria for a diagnosis of mental health disorder. Moreover, the Veteran's transient periods of depression and/or anxiety were either not significant enough to warrant a DSM 5 diagnosis of a stress-related disorder, or they were not attributed to any disease or injury in service. Based on the foregoing, the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a psychiatric or mental health disorder during the relevant appeal period recent to the filing of the claim that is related to disease or injury in service. Accordingly, service connection for psychiatric disorder to include an anxiety disorder and/or PTSD is not warranted. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Berry, 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.