Citation Nr: 22010891 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 18-52 049 DATE: February 24, 2022 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), is denied. FINDING OF FACT The evidence of record persuasively weighs against finding that an acquired psychiatric disorder began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder 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 had honorable active naval service from August 2000 to August 2004. This matter is before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO)'s June 2014 rating decision. In March 2020, the Veteran appeared and testified at a Board videoconference hearing before the undersigned Veterans Law Judge. The transcript of that hearing is in the claims file. This issue was previously before the Board in July 2021 when remanded for further development. The Board finds that the RO has substantially complied with its remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), is denied. The Veteran contends a current acquired psychiatric disorder was aggravated by or otherwise related to active-duty 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, while the Veteran has current diagnoses of paranoid type schizophrenia and PTSD, and evidence shows that the Veteran faced disciplinary actions in service, the evidence of record persuasively weighs against finding that the Veteran's diagnoses of paranoid type schizophrenia and PTSD began during service or is otherwise related to an in-service injury, event, or disease. Social Security Administration records show the Veteran had PTSD that clearly and unmistakably predated service. VA treatment records show the Veteran was not diagnosed with paranoid type schizophrenia until 2008, years after separation from service. Further, the August 2021 VA examiner opined that the Veteran's paranoid type schizophrenia was less likely than not incurred in or caused by service or aggravated by service and the PTSD was less likely than not incurred in or caused by service or aggravated by service. The Veteran asserted that prior to service, if the Veteran did have PTSD, it was not severe, but became severe due to in-service trauma and has remained so and therefore should be considered aggravated by service. The Veteran asserted that schizophrenia was not present prior to service but started in service and has never gone away and therefore should be service connected. However, the August 2021 VA examiner found that these assertions were not supported by the overall evidentiary record. The August 2021 VA examiner found that the problems that the Veteran had in service that might have supported either assertionproblems such as getting into fights, isolating, hypervigilance, interpersonal issues, and anger issueswere all present long before service and were at least as bad. The August 2021 VA examiner found that psychotic symptoms suggestive of schizophrenia, on the other hand, were not present prior to, during, or in the immediate aftermath of service, based on most of the evidence. Two years after leaving the Navy the Veteran denied any such symptoms on a July 2006 SSA consultative examination, the only symptoms at that time being those caused by a "very serious history of neglect and trauma from his childhood." The VA examiner opined that the Veteran's current psychiatric disorders are less likely than not related to service. The VA examiner explained that there was no evidence of a PTSD Criterion A stressor during service, defined by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), as: "Exposure to actual or threatened death, serious injury, or sexual violence." The VA examiner explained that in the past the Veteran had not described any in-service events meeting that diagnosis, and did not at the examination, either, telling the examiner that the "trauma" consisted of "getting into fights" because the Veteran and peers "weren't getting along." The Veteran told a consultative examiner hired by the SSA that there were "five" fights. The Veteran reported that the abuse consisted of "them calling me 'sissy.'" Asked if there was any other form of abuse or mistreatment in service, the Veteran said, "no." The Veteran also described as a trauma "just being confined for six months to the ship" (i.e., on a sea deployment). The Veteran additionally described being singled out for extra duty. The VA examiner found that "none of these can reasonably be considered a traumatic event." The VA examiner noted that prior to service, the Veteran was exposed to years of abuse and neglect, "easily" meeting the DSM-5's definition. The VA examiner explained that this is why VA providers have long (since 2007) diagnosed PTSD due to "severe childhood neglect/trauma," which included beatings by his father and others, witnessing a rape ("I watched a man sexually assault a little girl" in the same car the veteran was sitting in), finding his father dead of a drug overdose at age eight, his mother dying when at age four, "just watching a lot of people do drugs" (both sides of the family) including his father who kept the Veteran in the house whenever shooting up and thus being a witness to this, and being left to fend for self sometimes for days at a time. The July 2006 SSA consultative examination showed that the Veteran "suffers from PTSD. It started when he was nine years old." The examination report noted that the Veteran "was not psychotic and had no hallucinations." The VA examiner opined that the PTSD clearly and unmistakably (undebatable) preexisted service. The VA examiner explained that the Veteran originally filed for service-connection in June 2006 because he "had child PTSD." The Veteran denied to the VA examiner nightmares about service events, but still had nightmares about childhood trauma. The VA examiner noted that the Veteran became clearly upset when talking about childhood trauma but showed no such emotion when talking about events in service. The Veteran was treated by mental health counselors for many years in childhood and early adolescence (1990-94). The Veteran described symptoms consistent with PTSD that pre-existed service, including nightmares, being fearful around father, isolating and shutting down emotionally, anger and aggression, and being hypervigilant and fearful of surroundings. He did have paranoid thoughts: feeling that someone will try to hurt him if they "know what he is up to." In July 2006, the SSA consultative examiner found that these feelings did not start during or after service but were clearly present growing up. The Veteran had reported that "when he was younger, living in his own home, whenever he left the house, he would get nervous." In January 2007, a VA psychiatrist noted that the Veteran "had anxiety laden dreams in childhood." The Veteran, the SSA consultative examiner wrote, "has a very serious history of neglect and trauma from his childhood that have left him with full blown PTSD and chronic depression." The VA examiner opined that the paranoid type schizophrenia did not clearly and unmistakably (undebatable) preexist service. The VA examiner explained that for "that diagnosis to be clearly and unmistakably shown to pre-exist service, there would have to be evidence of psychotic symptoms (delusions, hallucinations) prior to service, and/or he would have to have been diagnosed and treated for that condition prior to service." The VA examiner found no evidence of this. The July 2006 SSA consultative examiner indicated that the Veteran was not psychotic and had no hallucinations, was bright and articulate, had well-organized and goal-directed speech, and was very cooperative during the examination. The VA examiner found that "none of that is consistent with someone with schizophrenia, and it certainly is not consistent with the Veteran's severe social and occupational impairments since being diagnosed with schizophrenia years after service. The VA examiner opined that the PTSD clearly and unmistakably (undebatable) was not aggravated by service. The VA examiner explained that there is no evidence the PTSD increased in severity during service. The VA examiner found that the symptoms manifested in the same way during service as they did prior to service and did not become more frequent or more intense. If anything, the VA examiner found that the symptoms were worse before service. A July 2018 inpatient admission at the VA indicated: "He says that he had difficulty with behavioral issues (pushing teachers and always getting into fights in middle school and HS). He says he was getting into fights due to 'frustration.'" The SSA consultative examination shows the Veteran "was fighting with people in school including his teachers, which probably led to the counseling. He was arrested at the age of 15 for stealing from a store." The Veteran told the VA examiner, "I was getting into trouble in school" which included talking back to teachers and "fighting" with peers. A tendency toward self-isolation was also well established prior to service. The Veteran told the VA examiner that, because of various childhood traumas, "I would just isolate a lotI wouldn't talk to my stepmother or my aunt. I felt like I wasn't a part of them." The Veteran reported frequently leaving the house and being alone all day. "I kept to myselfI didn't talk much." The July 2006 SSA consultative examination described serious pre-service PTSD symptoms including hypervigilance, avoidance of social environments, and being nervous and paranoid around other people. The SSA consultative examiner wrote: "These feelings did not start during or after service but were clearly present growing up. When he was younger, living in his own home, whenever he left the house, he would get nervous." The VA examiner opined that the paranoid type schizophrenia was less likely than not aggravated by the Veteran's pre-existing PTSD. The VA examiner explained that the evidence is most consistent with the Veteran developing the symptoms of schizophrenia after service. The symptoms of that disease that the Veteran reported and are described in treatment records over the last 15 years are less likely than not aggravated by pre-existing PTSD. The VA examiner explained that this is because the schizophrenia symptoms are not more severe and disabling than is typical of someone with that diagnosis. The VA examiner explained that the natural progression of that disease, in other words, includes the same types of behaviors and level of occupational and social impairment the Veteran has long exhibited. The VA examiner found that there is no need to reference the PTSD to explain the Veteran's severely impaired emotions, behavior, and thought processes. The August 2021 VA examiner's opinions are probative, because they are 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). The evidence of record is consistent with the August 2021 VA medical opinion. Preservice medical treatment records include January 1991 and April 1994 therapy notes. The Veteran also reported physical abuse. The therapist diagnosed dysthymia and "extreme" PTSD after the death of both parents and continuing treatment during this period. The therapist listed "acting out behavior," "depression," and "academic difficulties" as problems. Service treatment records were silent for mental health complaints or treatment. The Veteran denied any mental health or behavioral conditions in Reports of Medical History from July 2000, March 2001, and June 2004; a November 2003 pre-deployment health questionnaire; and a January 2004, however. A Report of Medical Examination from July 2000 showed "Normal" psychiatric clinical evaluation. Beginning in 2006, the Veteran began post-service mental health treatment and homelessness support at VA. In January 2006, the Veteran was noted as coping with both homelessness and unemployment. In July 2006, the Veteran applied for SSA disability benefits, alleging an onset date in August 2004, which coincides with separation from active service. An SSA psychiatric consultant, while finding mental functional capacity limitations, also found "insufficient" psychiatric evidence to support the alleged onset date of August 2004. A May 2006 VA psychology noted included an assessment of depression and anxiety. The Veteran reported getting into fights during service and had "threatened someone." In November 2006, a VA social worker noted diagnoses of "PTSD, GAD, panic attacks with agoraphobia." In May 2011, the Veteran was noted to be "continuing to work towards more independent living." The Veteran was prescribed medication. By January 2007, the Veteran and had stopped taken the medication and came to a VA hospital to detox from alcohol. The Veteran reported being depressed about the way "I am living, homeless, uncomfortable unstable." The VA psychiatrist found the Veteran's diagnosis was "unclear" other than mild alcohol abuse and "perhaps a personality disorder with dependent traits." In February 2007, the Veteran reports an overall positive experience in the military, but did note "breaking some simple rule, uniform codes, fighting... arguments." The Veteran confirmed seeing a therapist from 1989-97 (ages 8-17) but had no psychiatric evaluation while in the military. In August 2008, a VA licensed nurse practitioner noted "PTSD, bipolar disorder, OCD, panic disorder, anxiety disorder." In October 2008, a VA psychiatrist diagnosed "schizoaffective disorder bipolar type, at least partial PTSD from childhood, anxiety not otherwise specified, and a history of alcohol overuse and may abuse," but noted this was difficult because of the Veteran's "vagueness and denial of past events." The Veteran continued mental health treatment and housing support from VA from December 2010 through September 2015. In July 2016, the Veteran underwent a continuing disability review by SSA which included a consultative examination. He discussed childhood trauma and self-isolation. The Veteran also reported trouble getting along with other people in the military and getting into five fights. He reported getting into street fights after the military, not getting along with family, and homelessness. The psychologist diagnosed chronic PTSD, dysthymic disorder, and paranoid personality disorder. Another SSA psychological consultant noted a history of schizophrenia of at least two years that caused "moderate" work limitations, was "relatively stable" with medication, and a residual disease process that has resulted in such marginal adjustment that even a minimal increase in demands or environmental change would be predicted to cause the individual to decompensate. The Veteran continued to receive VA psychiatric treatment from August 2016 through October 2021. In September 2016, a VA psychologist opined that the Veteran "appears to be competent to handle his own financial affairs independently." In August 2021, the Veteran underwent a VA examination. The VA examiner diagnosed paranoid type schizophrenia and PTSD and was unable to differentiate symptoms. The VA examiner found total occupational and social impairment. The Veteran reported a childhood marked by "severe" neglect and physical abuse, family drug use, and self-isolation. He reported fighting in school and was arrested for stealing at age 15. He reported no traumatic events during service. "As soon as he got into the military, he realized that this was not for him, but he found a way to get through his service. He left the military "because he served his term and did not wish to continue." The Veteran denied any current legal issues. The VA examiner found the Veteran competent to manage financial affairs. The Veteran has a current psychiatric diagnosis, listed in January 2018 VA treatment notes as schizophrenia paranoid type versus schizoaffective disorder, PTSD, and a history of alcohol abuse. It is conceded that the Veteran has a long history of mental health diagnoses by providers; however the VA examiner found, "this in no way proves his symptoms started in service or were worsened by service." Military personnel records showed disciplinary actions during active service, including failure to obey regulations and missing physical training. The Veteran, has reported a history of behavior problems in childhood and adolescencenot just during service, or worsening in service. For example, a July 2018 VA psychiatry admission note reads: "He says that he had difficulty with behavioral issues (pushing teacher and always getting into fights in middle school and HS). He says he was getting into fights due to 'frustration.'" The Veteran told the VA examiner, "I was getting into trouble in school," which included talking back to teachers and "fighting" with peers. The Veteran was arrested at age 15 for stealing. The VA examiner found that the fights and disciplinary actions during active service, including failure to obey regulations and missing physical training, describe behavior that was no different than exhibited by the Veteran prior to service. The Veteran reported in July 2014 and May 2017 feeling singled out for extra duty with longer hours and fewer breaks than others. The Veteran alleged that these events contributed to a subsequent inability to cope with even minimally stressful situations. The VA examiner, however, found that these were not "traumatic" events. The VA examiner found that there is no evidence of a PTSD Criterion A stressor during service, the DSM-5 definition of which is: "Exposure to actual or threatened death, serious injury, or sexual violence." The VA examiner found that the Veteran has not described any in-service incidents or circumstances meeting this definition. The Veteran reported "trauma" consisting of "getting into fights" in boot camp, the shipyard, and out at sea, because the Veteran and peers "weren't getting along." The Veteran told the SSA consultative examiner there were "five" fights. The Veteran reported being called a "sissy." Asked if there was any other form of abuse or mistreatment, the Veteran said. "No." The Veteran also described as a trauma "just being confined for six months to the ship (in other words, being on a sea deployment) ... and at the same time not getting along with people on my watch team." The Veteran had also reported being singled out for extra duty. The VA examiner opined that merely being deployed to sea or singled out for extra duty, without more, "cannot reasonably be considered a 'traumatic event.'" The Veteran was discharged from service honorably after four years, having advanced in rank to an E4. The Veteran reported to the July 2006 SSA consultative examiner, two years after being discharged from service, that "as soon as he got into the military, he realized that this was not for him but he found a way to get through his service." This is inconsistent with the Veteran's allegation of being "unable to cope with even minimally stressful situations" at the time. At the March 2020 hearing, the Veteran testified to receiving mental health counseling prior to service due to the death of a parent during childhood. This evidence supports that the Veteran had a mental health condition (PTSD) prior to service. This does not show that the symptoms had started in service or were worsened by service. At the March 2020 hearing the Veteran denied getting into fights prior to active service. However, this was inconsistent with the rest of the evidentiary record, as described earlier in the section of the report. The Veteran reported many times, including at the August 2021 VA examination, about frequently being involved in fighting as a youth ("I was getting into trouble in school," which included talking back to teachers and "fighting" with peers). At the March 2020 hearing, the Veteran reported hearing voices during active service "but could quiet it." But this onset was inconsistent with other evidence of record. When asked directly by the August 2021 VA examiner, for example, the Veteran said the hallucinations started "probably after the service ... I believe back then." The Veteran then described their role in being hospitalized for the first time in 2006, two years after service. The July 2006 SSA consultative examiner indicated that the Veteran was not psychotic and had no hallucinations, was bright and articulate, had well-organized and goal-directed speech, and was very cooperative during the examination. The August 2021 VA examiner found this evidence was inconsistent with someone with schizophrenia at that time and inconsistent with the Veteran's severe social and occupational impairments since being diagnosed with schizophrenia years after service. At the March 2020 hearing, the Veteran testified to self-isolation, paranoia, being bullied and called names, and getting into "scuffles" during active service. The August 2021 VA examiner found that the tendency toward self-isolation and anxiousness around other people was well established prior to service. The Veteran told the VA examiner that because of various childhood traumas, "I would just isolate a lotI wouldn't talk to me stepmother or my aunt. I felt like I wasn't a part of them." The Veteran would frequently leave the house and be alone all day ("I kept to myselfI didn't talk much"). The 2006 consultative examination report noted that the Veteran "is extremely uncomfortable around other people and feels very nervous in their presence and is unable to be in social environments because of this. . . . These feelings did not start during or after service but were clearly present growing up. When he was younger, living in his own home, whenever he left the house, he would get nervous." Regarding "scuffles" during active service, the Veteran told the SSA consultative examiner in 2006 (two years after service) that there were "five" fights in total. The August 2021 VA examiner found that this was not suggestive of more physical confrontations than during childhood and adolescence, when it appears the Veteran was fighting fairly frequently. At the March 2020 hearing, the Veteran testified to homelessness "almost right after" active service and engaging in behavior that scared family members. This is also inconsistent with other evidence of record. The Veteran told the July 2006 SSA consultative examiner, two years after being discharged from service, about not seeing family in two years "because he cannot get along with his brothers because they are both heroin users." The Veteran reported living with family soon after leaving the military, but "both sides of the family were having a lot of trouble, so he went out to live on his own." It was only after that the Veteran became homeless. A January 2006 VA social work note indicated the Veteran "has been homeless about six months." This would mean homelessness started somewhere around mid-2005, almost a year after discharge, not "almost right away" as the Veteran claimed during the 2020 hearing. The Veteran believes the paranoid type schizophrenia and PTSD was aggravated by or are related to an in-service injury, event, or disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex. Therefore, it is outside the competence of the Veteran in this case because the record does not show that the Veteran 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). The Veteran is competent to report both symptoms and medical history. The Board gives the Veteran's March 2020 and other lay statements little probative value to the extent they are inconsistent with other evidence of record that the Board finds has more supports in the facts and data as noted above. Consequently, the Board gives more probative weight to the August 2021 VA medical opinion. Therefore, for the reasons outlined above, the Board finds that the preponderance of probative evidence is against the claim of entitlement to service connection for an acquired psychiatric disorder. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b). The claim is denied. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James Hekel 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.