Citation Nr: 21042252 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-14 131 DATE: July 12, 2021 ORDER Service connection for an acquired psychiatric disorder, to include bipolar disorder, anxiety, depression, alcohol dependency, adjustment disorder with mixed disturbances of emotions and conduct, and posttraumatic stress disorder (PTSD) is granted. Service connection for heart disease is denied. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disorder, to include depression/anxiety, bipolar disorder, PTSD, and adjustment disorder with mixed disturbance of emotions and conduct, as likely as not, had its onset during active service. 2. The Veteran's heart disease, diagnosed as coronary artery disease (CAD), did not have its onset during active service and is not otherwise related to any disease or injury in service, to include as secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for heart disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1976 to September 1977. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2014 Regional Office (RO) rating decision. In that rating decision, the RO denied, inter alia, service connection for bipolar disorder, depression, anxiety, alcohol dependency, and CAD, to include as due to anxiety, depression, and as secondary to bipolar disorder. In April 2021, the Veteran testified at a virtual hearing at the RO before the undersigned Veterans Law Judge. A transcript of his testimony is associated with the claims file. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 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 between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310. 1. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, anxiety, depression, alcohol dependency, adjustment disorder with mixed disturbances of emotions and conduct, and PTSD The Veteran contends that his acquired psychiatric disorder is related to service. The issue on appeal was previously characterized as separate issues of entitlement to service connection for anxiety, depression, and alcohol dependency. A claim for service connection for a psychiatric disability is deemed to encompass all psychiatric diagnoses reasonably presented in the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Veteran's anxiety, depression, and alcohol dependency claims are characterized in this appeal as an acquired psychiatric disorder which may encompass all possible diagnoses. All veterans are considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at(b) (1). If a disorder was not "noted" on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that the "increase in disability [was] due to the natural progress of the preexisting condition." 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If the government fails to rebut the presumption of soundness, the claim is one for service connection, not aggravation. Wagner, 370 F.3d at 1097. Here, as discussed below, while post-service medical evidence shows that the Veteran's acquired psychiatric disorder may be related to abuse that the Veteran suffered during his childhood, upon entrance to service, there is no indication of a condition related to the Veteran's mental health pre-existing service. In the July 2014 VA medical opinion addendum, the VA examiner stated that the Veteran's mental health symptoms were not evident or diagnosed upon entrance examination but that there is no rationale or basis to discount the Veteran's self-report that his symptoms were related to severe abuse he suffered during childhood. Despite the July 2014 VA examiner's assertion, the fact remains that there is no indication upon the Veteran's entrance into service that his mental health symptoms were noted at that time, nor that even if he had symptoms prior to service, that they were not aggravated by service. As such, the presumption of soundness attaches, and the Veteran is presumed sound at entry with respect to the claim of service connection for an acquired psychiatric disorder. VA treatment records, VA examination reports, and private records show diagnoses including depression/anxiety, bipolar disorder, PTSD, and adjustment disorder with mixed disturbance of emotions and conduct. Service treatment records (STRs) include the August 18, 1976 enlistment examination, showing that the psychiatric clinical evaluation was normal. In the report of medical history, the Veteran marked no for heart trouble, frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, nervous trouble of any sort, or periods of unconsciousness. Military personnel records show that the Veteran was discharged for failure to maintain acceptable standards for retention (expeditious discharge program). His commanding officer stated that it was proposed that he be discharged because of his inability to adapt emotionally and that the action was initiated because of his hostility toward the Army. It shows that the Veteran was counselled 6 times concerning his deficiencies. The Veteran underwent a VA examination in May 2014 for mental disorders, where the examiner stated that it is less likely as not that the Veteran's diagnosed bipolar I disorder is related to his complaints noted at discharge from service. The examiner stated that it is most likely that the Veteran's mental health diagnosis is related to his history of severe childhood sexual, physical, verbal, and emotional abuse. In a July 2014 VA addendum medical opinion, the VA examiner opined that the Veteran's diagnosed bipolar disorder was less likely than not incurred in or caused by the claimed in service injury event or illness, noting that it is less likely as not related to his complaints noted on discharge. The examiner's rationale was that the Veteran's service records do not show any evidence of bipolar or other mental health diagnosis or treatments. The examiner noted that a report of mental status evaluation on August 31, 1977 shows that he experienced situational adjustment difficulty, has projected blame for his problems onto the Army, is passive aggressive and mildly hostile, has no evidence of significant mental illness, and was cleared for administrative disposition. The examiner stated that the Veteran reported that his mental health symptoms were related to his experiences during childhood and that the Veteran's assertions that his symptoms occurred as a result of childhood stressors or trauma, does not contradict the fact that there is no mental health condition shown on his entrance examination. Although his mental health symptoms were not evident or diagnosed on his entrance examination, there is no rationale or basis to discount the Veteran's self-report that his symptoms were related to the severe abuse he suffered during childhood. The examiner stated that because the onset of his symptoms occurred after his entrance examination does not mean that his self-report is inaccurate. The Board notes that, as discussed above, the Veteran was found to have been sound upon entrance to service. While the VA examiner stated that the timing of the onset of his symptoms does not mean that his self-report is inaccurate, such timing of the onset is a crucial element in determining whether the onset of his symptoms occurred during service. In a November 2014 private medical opinion, the Veteran's treating therapist stated that he had been providing mental health treatment to the Veteran since July 2013. The examiner stated that although it has been determined in his records that the Veteran suffers from bipolar disorder and PTSD since the age of 19, his age upon separation from service, as a result of sexual physical and verbal abuse experience during his childhood, he found that the Veteran's bipolar disorder and PTSD were aggravated as a direct result of his treatment in the military by his commanding officers. The examiner stated that the Veteran's diagnosis of PTSD is interconnected with his bipolar disorder in such a way that the one disorder exacerbates the other. The examiner found that his bipolar disorder and PTSD had been aggravated by service, explaining that not only did the treatment he received from his commanding officers aggravate his mental health status, but the fact that they resembled the perpetrator of his earlier abuse, was an aggravating factor. The examiner pointed out that the report of medical history in the August 1977 separation examination shows that he was experiencing depression or excessive worry, and that the Veteran has been dealing with symptoms ever since service but had been untreated until now. The Veteran underwent a VA examination in February 2017 for mental disorders. The examiner opined that it is less likely as not that his current diagnosis of adjustment disorder with mixed disturbance of emotions and conduct first began during his period of military service. The examiner stated that a thorough review of military records showed no diagnosis of any significant mental illness. The Veteran reported that after finding out about his wife's infidelity, he did not want to be controlled by the Army or anyone. The examiner noted that records from that time show that the Veteran was "experiencing situational adjustment difficulty and has projected blame for his problems unto the Army," described the Veteran as "passive aggressive and mildly hostile," noted "no evidence of significant mental illness," and that he was "cleared for administrative disposition." The examiner stated that difficulties associated with the Veteran's belief that he was "good for nothing" and not emotionally mature enough to handle personal problems also contributed to his difficulties. The examiner stated that the Veteran's beliefs and personality traits predated service and impacted his ability to cope with the stress associated with his wife. The examiner stated that during service, the Veteran endorsed depression or excessive worry on a medical history form, but that the symptoms were not noted to be at a clinical level by military personnel. The February 2017 VA examiner opined that it is less likely as not that the Veteran's diagnosed adjustment disorder with mixed disturbance of emotions and conduct was caused by or the result of his treatment in the military by his commanding officers. The examiner explained that despite the Veteran's reports that his Drill Sergeant in basic training reminded him of his abusive older brother, he was able to complete basic training and reported that he did well in school for his military occupation specialty. The examiner noted that it was only after he discovered his wife's infidelity that he began to struggle. The February 2017 VA examiner also stated that treatment records from 2013 do not mention psychiatric symptoms related to his treatment by military personnel in service but rather focus on childhood abuse. The examiner explained that his mental health symptoms are best explained by severe childhood abuse, with a significant increase in psychiatric symptomatology and associated functional decline following his becoming aware of infidelity by his wife and their eventual divorce, noting that this opinion was in contrast with the Veteran's treating therapist. The examiner stated that it is not evident from the record and clinical interview that his diagnosed bipolar disorder and PTSD were aggravated as a direct result of his treatment in the military by his commanding officer or by other aspects of his military service. The February 2017 VA examiner opined that it is less likely as not that his current diagnosis of adjustment disorder with mixed disturbance of emotions and conduct has been permanently aggravated beyond normal progression by his treatment in the military by his commanding officers. The examiner explained that it appeared that the Veteran's mental health status changed only after finding out about his wife's infidelity, unrelated to his military service. At the time the Veteran learned of his wife's infidelity, he had successfully completed basic training and reported having recovered from any emotional distress, with no associated functional impairment, prompted previously by similarity in appearance and manner between a commanding officer and an abusive sibling. The February 2017 VA examiner opined that it is less likely as not that an alcohol and/or other substance use disorders were either caused by or permanently aggravated beyond normal progression by another psychiatric disorder. At the time of evaluation, his symptoms of criteria alcohol use disorder and or other substance use disorder were in sustained remission. The examiner noted that the criteria for this condition was previously met, but that the mere fact that they are in sustained remission, shows that neither disorder was caused by or permanently aggravated beyond normal progression by another psychiatric disorder. During the April 2021 Board hearing, the Veteran testified that prior to service he was working and going to school, had his own apartment, and that his issues and interactions with his brother were normal between brothers of different ages. He testified that prior to service he did not have mental health concerns, and that they began in service. He stated that during military service he learned that his spouse was unfaithful, and that because he was upset, he was told to see a doctor, who told him that he was bipolar and was having anxiety issues. The Veteran indicated that after learning of his wife's infidelity during service, he received an honorable medical discharge. He testified that he has had mental health problems since service to the present and began receiving treatment after service, about seven or eight years ago. He stated that he did not know he could have received treatment prior to that time, and had been previously self-treating with cocaine, alcohol, and marijuana. He stated his current psychiatrist, Dr. D. prescribes medication but that his therapist, Dr. F., has since retired. In summary, during service, the Veteran had some mental health complaints, shown in his treatment records, and those mental health problems were based on personal difficulties with his spouse at that time, unrelated to the military. Based on the above, the evidence is at least in relative equipoise as to whether the Veteran's acquired psychiatric disorder, claimed as bipolar disorder, anxiety, depression, alcohol dependency, adjustment disorder with mixed disturbances of emotions and conduct, and PTSD, had its onset during service or is otherwise related to service. The Veteran has a current acquired psychiatric disorder, with diagnoses including depression, anxiety, bipolar disorder, PTSD, and adjustment disorder with mixed disturbance of emotions and conduct. While there is evidence to indicate that the Veteran may have suffered abuse prior to service, there is no indication upon entrance that he had a diagnosis or was experiencing symptoms of an acquired psychiatric disorder; therefore, the Veteran was sound upon entrance. He reported that symptoms related to his acquired psychiatric disorder began during service, coinciding with the time that he learned of his wife's infidelity. As discussed above, service records show that he reported depression and excessive worry upon examination in August 1977, and it was determined by military personnel that he was not emotionally mature enough to handle personal problems of a certain magnitude and that no possible improvement was expected in the foreseeable future. The probative medical evidence of record shows that the Veteran has been experiencing symptoms related to his diagnosed acquired psychiatric disorders since service, and there is no evidence to show that his symptoms have not been continuous since service. While acknowledging a lack of documented treatment close in time to his separation from service, the Veteran has credibly testified that he was self-treating for years prior to receiving treatment from medical professionals for his symptoms. A corroborated stressor is not required to establish service connection for an acquired psychiatric disorder other than PTSD. As such, as his symptoms of an acquired psychiatric disorder had their onset in service, eventually resulting in the diagnosis of the above listed mental health conditions, the Veteran is entitled to service-connection for an acquired psychiatric disorder. The Veteran has a current condition, and related complaints and treatment are noted in service records. Competent medical evidence of record does not indicate that the Veteran's acquired psychiatric disorder, to include depression/anxiety, bipolar disorder, PTSD, and adjustment disorder with mixed disturbance of emotions and conduct, is not at least as likely as not related to active service. Thus, service connection for an acquired psychiatric disorder is warranted, as the conditions cannot be satisfactorily disassociated from service. 2. Entitlement to service connection for heart disease The Veteran contends that his heart disease is related to active service, to include as due to his acquired psychiatric disorder. The questions for the Board are 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, or alternatively, whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by his now service-connected acquired psychiatric disorder. The Board concludes that, while the Veteran has a current diagnosis of CAD, and evidence shows that there is an in-service report of "intermittent ant chest pain which seems anxiety-related," the preponderance of the evidence weighs against finding that his diagnosis of CAD began during service or is otherwise related to an in-service injury, event, or disease and that the Veteran's CAD is not proximately due to or the result of, or aggravated beyond its natural progression by his service-connected acquired psychiatric disorder. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). STRs include the August 18, 1976 enlistment examination, showing that upon clinical evaluation, the Veteran's heart was normal. In the report of medical history, he marked no for heart trouble; he did make a note of high blood pressure once. Military personnel records show that in an EPD examination on August 29, 1977, report of medical history, the Veteran noted yes for pain or pressure in chest. Clinical evaluation shows clinical evaluation was normal for heart, and the physician noted "intermittent ant chest pain which seems anxiety-related." The May 2014 VA examination report shows a diagnosis of CAD from April 13, 2010. Private treatment records include an April 13, 2010 record indicating hospital admission. It shows that the Veteran is an active tobacco user, does not drink alcohol, and has a notable, extensive family history for CAD. VA treatment records received in April 2021 include a June 19, 2019 record indicating that the Veteran quit smoking in 2010. It shows palpitations, severe CAD, preserved LVF, tobacco dependence, hyperlipidemia, and obesity. There is also a June 2010 report of office visit indicating that, "There is a family history of premature coronary artery disease." This has affected three brothers, two sisters, and the Veteran's mother. During the April 2021 Board hearing, the Veteran testified that he had his first close encounter with his heart problems, after beginning treatment for mental health issues about seven or eight years ago. He indicated that his service records contain a report of intermittent chest pain in August of 1977, noting that it was from when he was running and blew out his knee and then started to have chest pains. He stated that it was worse than heartburn but that he did not get treatment for it. The Veteran stated that began having chest pains, off and on, eventually worsening to the point where he was told he was having a heart attack and now has eight stents. He stated that he was told a lot of it has to do with his stress and anxiety, noting that it is all related to his mental health condition from service. Private and VA treatment records show the Veteran was not diagnosed with CAD until April 2010, more than 30 years after his separation from service. The Veteran believes his CAD is related to service, as related to a report of intermittent chest pain symptoms during service, or, alternatively, as secondary to his now service-connected acquired psychiatric disorder. While the Veteran is competent to report experiencing observable symptoms such as chest pain, he is not competent to provide a diagnosis of CAD or a nexus opinion. The cause of heart disease is medically complex issue, as it requires advanced medical knowledge regarding the interaction between multiple organ systems in the body and mental health conditions. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent medical evidence of record. The February 2017 VA examination report shows confirmed diagnosis of acute, sub-acute, or old myocardial infraction from April 13, 2010 and CAD from April 13, 2010, and the examiner opined that the Veteran's CAD is less likely as not related to the active military service intermittent chest pain symptoms. The examiner opined that the Veteran's CAD is less likely as not related to the active military service intermittent chest pain symptoms, noting chest x-ray findings of slight left ventricular prominence with the cardiothoracic ratio being within normal limits. The examiner explained that the Veteran was 19 at separation from service, and that the incidence of CAD from age 20 to 39 is only .6 percent and even less at age 19. The examiner explained that medical research literature reveals that having symptomatic CAD at age 19 is highly unlikely, and it does not support that having a slight left ventricular prominence with the cardiothoracic ratio being within normal limits on chest x-ray to be associated with CAD. Regarding secondary service connection, the VA examiner opined that the Veteran's CAD is less likely as not caused by or a result of or permanently aggravated beyond natural progression by his psychiatric disorders. The examiner explained that he has several risk factors including hypertension, hyperlipidemia, and a prior smoking history of 37 pack years, that more likely as not led to his subsequent development of CAD, diagnosed in 2010, more than 30 years after service. The examiner stated that the relationship between psychiatric illness and heart disease is complex and not yet fully understood by medical researchers. He stated that although prospective medical research studies in different populations have found depressed patients have a one and a half to two-fold increased risk of IHD, a causative/aggravatory relationship has not clearly been demonstrated. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consequently, the Board gives more probative weight to the February 2017 VA examination and opinion indicating that the Veteran's CAD is less likely than not related to active service and less likely than not caused or aggravated by his service-connected acquired psychiatric disorder. Based upon the evidence of record, the Board finds that the Veteran's CAD did not manifest during service and that the preponderance of the evidence fails to establish that his CAD is etiologically related to service, to include as secondary to his service-connected acquired psychiatric disorder. The most competent and probative evidence of record does not attribute the Veteran's CAD to any event, injury, or illness associated with service, nor to a service-connected disability. (Continued on the next page) For the foregoing reasons, the preponderance of evidence is against the Veteran's claim of entitlement to service connection for heart disease, diagnosed as CAD. Consequently, the benefit of the doubt doctrine does not apply, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Labi, 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.