Citation Nr: 22012045 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 19-15 796 DATE: March 2, 2022 ORDER Service connection for an acquired psychiatric disability, to include claimed posttraumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during active service and was not exposed to hostile military or terrorist activity during active service. 2. There was no psychiatric injury or disease, including no stressor event, during service. 3. The current psychiatric disability was manifested many years after service separation and is not causally or etiologically related to service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include claimed PTSD, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran, who is the appellant, had active service from October 1960 to December 1963. This matter is on appeal from a July 2018 rating decision. In July 2021, the Board, in pertinent part, remanded the issue of service connection for an acquired psychiatric disability for clarification regarding whether the Veteran has been diagnosed with PTSD. The March 2021 rating decision finding incompetency noted that the Veteran had been diagnosed with PTSD and memory loss and cited the findings of a VA Initial PTSD Disability Benefits Questionnaire with no date specified. Only VA PTSD examination of record (i.e., in May 2018) noted that the Veteran did not meet the criteria for a diagnosis of PTSD and alternatively diagnosed adjustment disorder and delusional disorder. The Board directed the Agency of Original Jurisdiction (AOJ) to identify the date of the examination showing diagnosis of PTSD and associate the evidence with the record or issue a memorandum clarifying the error in diagnosis in the March 2021 rating decision and return the appeal to the Board. To comply with the Board's remand directives, the AOJ obtained the August 2021 VA addendum opinion noting that a February 2020 psychiatry consultation note showed a diagnosis of PTSD related to service but with no description of symptoms. In the August 2021 Supplemental Statement of the Case (SSOC), the AOJ wrote that the March 2021 rating decision noting that the Veteran had been diagnosed with PTSD was an error. The response was consistent with the February 2020 private psychiatry consultation report of record showing only a history of PTSD based on the Veteran's self-report but no actual diagnosis of PTSD. In consideration thereof, the Board finds that there was substantial compliance with the prior remand directives. The Board finds that the duties to notify and assist the Veteran in this case have been satisfied. Notice requirements were satisfied by way of the notice letter. The duty to assist has been met in this case. The complete service treatment records and relevant post-service treatment records are associated with the record. A VA examination with a medical opinion was provided in May 2018, and a supplemental VA medical opinion was obtained in August 2021. The Veteran has reported receipt of Supplemental Security Income from the Social Security Administration (SSA) due to physical disability; therefore, no request for SSA records is needed because such records would not be relevant to the issue on appeal. See May 2018 VA examination report. Service Connection for Psychiatric Disorder is Denied. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a direct basis when there is competent, credible evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. 38 C.F.R. § 3.303(a), (d). Service connection may be established on a presumptive basis for chronic diseases listed under 38 C.F.R. § 3.309(a) if chronic symptoms of the disease were shown in service; the disease was manifested to a compensable degree with a presumptive period, usually one year after service separation; or continuous symptoms of the disease were manifested since service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.33(b), 3.307, 3.309(a); see also Walker v. Shinseki, 708 F. 3d 1131 (Fed. Cir. 2013). Because the current diagnoses of adjustment disorder with mixed anxiety and depressed mood and delusional disorder, mixed type, which are not manifested by a psychosis, are not listed as chronic diseases under 38 C.F.R. § 3.303(b), the presumptive service connection provisions are not applicable. The Veteran contends that the current psychiatric disability is related to service. He alleges that he has PTSD due to the claimed stressor events of being locked up in Germany after allegations of mental illness (i.e., being crazy), being treated badly in the service, doing eight years of hard labor for being absent without leave (AWOL) for fifteen minutes, and losing rank. As a preliminary matter, the Board finds that the Veteran is not currently diagnosed with PTSD. At an April 2005 VA mental health consultation, where an initial intake screening interview for evaluation of PTSD was performed, the mental health provider wrote that the Veteran denied combat service and military sexual trauma. The examiner opined that the Veteran did not report any symptoms that would suggest PTSD from another source. More recently, at the May 2018 VA examination, the VA examiner reviewed the record, interviewed, and evaluated the Veteran, and opined that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-5 criteria. After review of the record, the August 2021 VA reviewer similarly opined that a description of symptomatology that would meet diagnostic criteria for PTSD that corresponded to a stressor had not been provided. After review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that there was psychiatric injury or disease during service. The service treatment records (STRs) are absent of any report, complaint, diagnosis, or treatment for mental health problems. The neurologic and psychiatric systems were clinically evaluated as normal at the October 1963 service separation examination. On the October 1963 service report of medical history, the Veteran checked "No" when asked if he then had or had ever had frequent trouble sleeping, depression or excessive worry, or nervous trouble of any sort. Because the service treatment records are complete and show no indication of mental problems or symptoms during service, while simultaneously documenting treatment for various other medical problems such as sinusitis and headaches, the Board finds that a psychiatric injury or disease, including symptoms related thereto, is a condition that would have ordinarily been recorded during service if it had occurred; therefore, the lay and medical evidence, which is likely to reflect accurately the Veteran's mental condition because it was generated contemporaneous to service and is absent of any complaint of, diagnosis of, or treatment for a psychiatric injury and disease is of probative value and weighs against finding of psychiatric injury or disease during service. The alleged claimed stressor events of being locked up in Germany after allegations of mental illness (i.e., being crazy) and doing eight years of hard labor for being absent without leave (AWOL) for fifteen minutes have not been corroborated by independent, supporting evidence. Rather, the service personnel records show confinement in Germany from May 1963 to July 1963 for a total of fifty days and reduction in rank to private E-1 after special-court martial proceedings found the Veteran guilty of being absent without leave for approximately 25 minutes in May 1963. After considering all the claimed stressor events reported by the Veteran, the May 2018 VA examiner opined that the stressors were not adequate to support a diagnosis of PTSD and the Veteran's reports of symptoms and stressors had not met the criteria for a stressor. The May 2018 VA examiner has medical training and expertise in the diagnosis of psychological disabilities, considered whether stressors sufficient to cause psychiatric disability had been reported, and had adequate facts and data on which to base the medical opinion that stressors were not adequate to support a PTSD diagnosis and did not meet criteria for a stressor; therefore, the May 2018 VA medical opinion is of significant probative value. The weight of the evidence is against finding that the current psychiatric disability otherwise was caused by or related to service. The weight of the lay and medical evidence shows no psychiatric symptoms or psychiatric diagnosis until many years after service separation. The earliest indication of psychiatric symptoms of record is shown in 2004, approximately 41 years after service. See October 2004 VA nursing note (noting a positive depression screen). The earliest diagnosis of a psychiatric disability is in 2018, approximately 55 years after service separation. Considered together with the absence of any complaint, symptoms, findings, diagnosis, or treatment for mental health problems during service, the 41-year gap or more between service separation and the onset of mental problems is one additional factor that weighs against service incurrence. The competent evidence is against finding a link between the current psychiatric disorder and service. No VA medical opinion was obtained in connection with this appeal on the question of nexus to service, and none is required because, as a matter of fact based on the weight of the evidence, there is not in-service injury, disease, or event to which the currently diagnosed disorder could be related. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (where the Board makes a finding that lay evidence regarding an in-service event or injury is not credible, the claim must be denied, and a VA examination is not required). Because any favorable nexus opinion would necessarily be based on an inaccurate factual assumption of some in-service psychiatric injury, psychiatric disease, or stressor event, which is contrary to the weight of the evidence and the Board's factual findings in this case, any nexus opinion based on such inaccurate factual assumption would be of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis but cannot reject the opinion solely because the history was from the veteran). As there is no reasonable possibility that a medical opinion would help substantiate the appeal, the Board finds that further development is not necessary. The February 2020 private psychiatry consultation report includes an assessment of a history of PTSD; however, the assessment was based solely on the inaccurate report of a history of PTSD related to service in Vietnam. The February 2020 private psychiatrist did not independently perform a mental evaluation of the Veteran to arrive at the PTSD diagnosis and acknowledged that she was awaiting VA treatment records to obtain additional information. The February 2020 VA examiner also noted an assessment of possible delusional disorder based on the son's report that the Veteran had begun delusional talk about a year earlier. In consideration thereof, the Board finds that the portion of the February 2020 private psychiatry consultation report noting a history of PTSD is of no probative value. The February 2020 private psychiatry consultation report also shows no relationship between a possible delusional disorder, which manifested more than five decades after service separation, and service. The Veteran, as a lay person, is competent to report any psychiatric symptoms he has experienced at any given time; however, under the facts of this case, which include no in-service stressor or psychological injury, disease, or symptoms, and as relates to the period of time before the Veteran became delusional and was declared incompetent, he was not competent to diagnose a psychiatric disability or render a competent medical opinion on the question of causation or etiology because answers to such questions require medical expertise in the area of psychiatric disorders and falls outside the realm of common knowledge of a lay person. See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (holding that "PTSD is not the type of medical condition that lay evidence . . . is competent and sufficient to identify"). The weight of the evidence shows nothing in service to which the current psychiatric disorder could be related. In summary, the weight of the lay and medical evidence of record shows no in-service injury, disease, or event to which the current psychiatric disorder could be related; therefore, the appeal for service connection for an acquired psychiatric disability, to include claimed PTSD, must be denied. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Palmer, 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.