Citation Nr: 22017085 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 16-52 153 DATE: March 24, 2022 ORDER Entitlement to service connection for acquired adjustment disorder with anxiety and depressed mood due to service-connected duodenal ulcer disease, status post vagotomy and antrectomy with Billroth II anastomosis and dumping syndrome, for the purpose of entitlement to accrued benefits, is granted. FINDING OF FACT The Veteran's acquired adjustment disorder with anxiety and depressed mood was aggravated by his service-connected duodenal ulcer disease. CONCLUSION OF LAW The criteria for a grant of service connection for acquired adjustment disorder with anxiety and depressed mood for purposes of accrued benefits have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107, 5121; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.1000. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from January 1963 to January 1965. The Veteran died on November [REDACTED], 2019. The Veteran filed a claim for a nervous condition related to his stomach surgery in June 1978. The claim was denied in July 1978. In May 2013, the Veteran filed a claim for service connection for mental health conditions. A July 2013 rating decision denied the claim for service connection for depression/depressive reaction as secondary to the service-connected disability of duodenal ulcer disease, status post vagotomy and antrectomy with Billroth II anastomosis and dumping syndrome because the evidence submitted was not new and material. The Veteran filed a notice of disagreement in March 2014. An October 2016 statement of the case continued the denial of the claim for service connection because the evidence submitted was not new and material. A December 2018 Board decision granted the Veteran's petition to reopen the previously denied claim for service connection for depression, claimed as secondary to duodenal ulcer disease and remanded the issue of service connection for depression to obtain an addendum opinion regarding whether the Veteran's acquired adjustment disorder with depressed mood was at least as likely as not aggravated beyond its natural progression by service-connected duodenal ulcer disease. The Board then remanded the claim again in September 2021. In that remand, the Board explained that the appellant, the Veteran's surviving spouse, was appropriately substituted as the appellant via correspondence in January 2020. The Board also found that the June 2021 addendum opinion was inadequate as it was conclusory in discounting the Veteran's diagnosed acquired psychiatric disorders and failed to account for the diagnosis of psychiatric disorders in the Veteran's VA treatment records. The Board notes the appellant's attorney submitted a "motion to vacate BVA decision September 8, 2021" in December 2021. The attorney explained a motion had been submitted in August 2021, in which the appellant's attorney requested the Board wait 90 days before adjudicating the claims to allow time to submit evidence and argument in support of her claims and the motion was not ruled on before the September 8, 2021, decision, nor had 90 days passed. The attorney contends the September 8, 2021, Board decision constitutes denial of due process for the Veteran. The attorney requested the September 8, 2021, decision to be vacated and the Veteran's brief and evidence submitted November 9, 2021, should be considered. The Board notes that the September 8, 2021, Board document was not a decision, rather it was a remand. A decision on the issue of service connection has not been issued until now. The November 9, 2021, evidence has been considered here. Neither the Veteran nor the appellant has been denied due process. Entitlement to service connection for an acquired psychiatric disorder due to service-connected duodenal ulcer disease The Veteran contended that his acquired psychiatric disorder was due to his service-connected duodenal ulcer disease status post vagotomy and antrectomy with Billroth II anastomosis and dumping syndrome. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. In this case, the Veteran was service connected for duodenal ulcer disease status post vagotomy and antrectomy with Billroth II anastomosis and dumping syndrome, and he had diagnoses of an acquired psychiatric disorder, to include acquired adjustment disorder with anxiety and depressed mood. Therefore, the relevant inquiry is whether his acquired psychiatric disability was caused or aggravated by his service-connected duodenal ulcer disease. The Veteran was evaluated by a private psychologist, Dr. H.H.G., in January 2014 (received March 2014). At that time, the Veteran reported he did not leave the house much because of dumping syndrome (sudden onset of need to evacuate bowels) related to his service-connected duodenal ulcer disease. She explained in a January 2014 assessment (received March 2014) that the chronic pain and dumping syndrome complications related to his duodenal ulcer disease continued to manifest as a mood disorder. She opined the duodenal ulcer disease caused the mood disorder. She explained there is a body of literature detailing the connection between chronic disease with pain and mood disorders. She noted there is a causal relationship between chronic disease with pain and mood disorders. She concluded it was her belief, based on the interview and the C-File that the Veteran's service-connected duodenal ulcer disease was more likely than not aggravating his mood disorder. A September 2016 VA examiner diagnosed the Veteran with alcohol abuse disorder in sustained remission. She noted psychiatric hospitalizations-7N at Lou VAMC in 2005 with a discharge diagnosis of alcohol dependence, alcohol induced mood disorder, rule out major depressive disorder recurrent. The Veteran reported he was in OLOP in the late 90s for substance abuse. Health record noted in the electronic record says he reported being in OLOP for 30-day programs in 1977 and 1983. The examiner asked the Veteran who Dr. H.H.G was. He said he did not know and that he never saw her for mental health treatment to his knowledge. He reported all his mental health treatment was through VA. His only mental health medication was bupropion, which was commonly prescribed for smoking cessation purposes. The examiner opined that the Veteran's alcohol abuse in sustained remission was less likely than not proximately due to, aggravated by, or the result of duodenal ulcer disease, status post vagotomy and antrectomy with Billroth II anastomosis and dumping syndrome. The more likely relationship between the disorders was that, when he was actively abusing alcohol, his alcohol consumption negatively impacted his physical health, including his gastrointestinal (GI) condition. The Veteran reported he first drank alcohol at age four, and had a history of drinking to intoxication before joining the Navy at 17. The examiner found him to have no other psychiatric disorder. The examiner indicated the reaction the Veteran described to his physical health problems (mostly his left leg amputation; he hardly mentioned his GI problems during the 1.75 hour clinical interview) was within the realm of normal response and was not suggestive of psychopathology. The examiner noted the Veteran saw no mental health treatment providers. In a June 2021 addendum opinion, a VA clinician who reviewed the Veteran's records found it was less likely than not that the Veteran's acquired adjustment disorder with depressed mood was aggravated beyond its natural progression by service-connected duodenal ulcer disease. She explained the September 2016 VA examiner did not diagnose the Veteran with adjustment disorder and only diagnosed him with alcohol abuse disorder in sustained remission. The September 2016 VA examiner documented in her report that the Veteran had a history of drinking to intoxication before joining the Navy at age 17 and had abused alcohol for decades. She also documented in her report that the Veteran's alcohol consumption had negatively impacted his physical health, including his GI condition, and had contributed to his marital divorce, homelessness, four DUI charges, and three public intoxication charges. The June 2021 VA examiner explained she disagreed with the private clinician's diagnosis of mood disorder secondary to medical condition. She explained per the DSM IV-TR manual, the diagnosis of mood disorder secondary to a general medical condition requires the persistent disturbance in mood be due to the direct physiological effects of a general medical condition. She explained the private clinician provided no evidence that the Veteran's mood disturbance is the direct physiological effect of any of his medical conditions. She further explained the diagnosis of adjustment disorder secondary to the service-connected duodenal ulcer disease was also incorrect, as it assumed that the Veteran's mood symptoms were in response to a situational stressor, his service-connected duodenal ulcer disease. Such an assumption does not consider the negative impact of alcohol on mood. The flat affect, anxiety, chronic sleep impairment, and intermittent inability to perform activities of daily living that the private examiner conceptualized as being part of the Veteran's emotional response to the situational stressor of having service-connected duodenal ulcer disease could all be the result of the heavy alcohol consumption. In a 2009 scientific article, the authors explained that the associations between alcohol abuse or dependence (AAD) and symptoms of depression were best explained by a causal model in which problems with alcohol led to increased risk of symptoms of depression as opposed to a self-medication model in which symptoms of depression led to increased risk of AAD. In an October 2021 VA disability benefits questionnaire (DBQ) the VA clinician indicated diagnoses of alcohol use disorder and adjustment disorder with anxiety and depressed mood, chronic. The clinician indicated there was overlap in symptoms between the diagnoses. The clinician noted no relevant pre-military mental health or behavioral history. In her October 2021 opinion, she noted the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. She noted the Veteran's substance abuse and mild anxiety and depression; however, there was a lack of substantial records to make a nexus between the conditions. In the absence of any other substantial records to support the claim, the medical opinion of 2021 appears sound. There was no evidence to indicate a connection, or a progression based on physical health conditions. She also determined that the Veteran's condition was not at least as likely as not aggravated beyond its natural progression by the service-connected condition. She did not provide a rationale for this opinion. Thus, an addendum opinion was requested of her. In November 2021, the October 2021 VA examiner provided an addendum opinion and explained that she found no information in the records to refute the 2021 opinion offered, failing to find a connection between health conditions and mental health conditions. She indicated that the Veteran's substance abuse and mild anxiety and depression were noted; however, there was a lack of substantial records to make a nexus between the conditions. In the absence of any other substantial records to support the claim, the medical opinion of 2021 appears sound. There is no evidence to indicate a connection or a progression based on physical health conditions. The examiner indicated, "there is no evidence to support or supply, therefore a connection or support for aggravation cannot be made. The Veteran's mental health symptoms appear unrelated to health." In a November 2021 letter from Dr. H.H., the private psychologist who evaluated the Veteran in January 2014 (at which time she signed as Dr. H.H.G.), she concluded it is more likely than not the Veteran's mood disorder developed secondary to his duodenal disease with dumping syndrome. She noted the Veteran engaged in alcohol abuse disorder in self-medication of his mood disorder. Dr. H.H. explained that in the Veteran's consultation with her in January 2014, he expressed he did not leave the house because he was afraid of being too far away from a bathroom. He described his feelings as paralyzing fear. Dr. H.H. explained she agreed with the VA examiner that the Veteran's alcohol abuse worsened his duodenal disease, and this created a cyclical relationship between the worsening of the conditions. She could not agree the Veteran's alcohol abuse disorder began prior to service nor was the root of his mood disorder. She noted there were no reports of any problems socially, occupationally, or legally prior to service. While he was no stranger to alcohol, he maintained employment prior to service, stayed out of trouble, and had no issues in school other than not being academically inclined. Additionally, he was given a clear entrance examination into service with the presumption of soundness which has not been rebutted. He reported his drinking spiraled out of control after his discharge from service and his alcohol abuse only became an issue for him in adulthood. The Veteran's duodenal disease began in service. He reported he had quite a few stomach problems in service and reported nervous stomach on his military exit exam. As his physical condition worsened because of his duodenal disease so did his alcohol abuse, as a method of self-medication of his emerging mood disorder caused by his failing physical health and effects of his duodenal disease. (Continued on the next page) Significant weight is afforded the opinions of Dr. H.H. considering her expertise, consideration of evidence, and rationale. Little weight is afforded the opinion of the September 2016 VA examiner who found the Veteran did not have a mental health diagnosis other than alcohol abuse disorder. The Veteran's treatment records reflect he was seen for mental health treatment, including in October 2013 when a diagnostic impression of depression, not otherwise specified was noted. At that time, it was noted he was mainly upset that he was unable to do the things he used to, and he was consumed by much anger at VA for his knee surgery and delay in his care. The Board notes that the record does not contain corroborating medical records discussing the effect of the Veteran's duodenal disease on his mental health. However, while the Veteran "hardly mentioned" his GI problems during the 1.75 hour clinical interview with the VA examiner in September 2016, it is certainly possible that his GI problems had an effect on his mental health, but such problems seemed minimal to the Veteran compared to his main concern at the time, which was the amputation of his leg. The record reflects the Veteran was frustrated with his treatment at the VA and struggled to navigate his care. It appears that Dr. H.H. specifically asked the Veteran about his GI concerns, which perhaps elicited different information than what was obtained by other clinicians. While the September 2016 VA examiner also put stock into the Veteran's comment that he did not remember seeking treatment from Dr. H.H., the Board notes that his examination with her was two years prior; he did not receive ongoing treatment with her; and he was occupied with other serious medical concerns and may not have recalled his visit with her during the VA examination. Additionally, the record reflects there is a difference in professional opinion about the possibility of causation. However, with respect to aggravation, in the November 2021 VA addendum opinion, the examiner indicated there was no evidence to note aggravation from the Veteran's physical health conditions. However, it is unclear if the VA examiner considered all the evidence of record, including lay statements. The record reflects the Veteran started complaining of mental health concerns related to his GI condition in 1978. Upon review of the record, the Board finds the evidence to at least be in approximate balance as to whether the Veteran's acquired mental health disability was aggravated by his service-connected duodenal ulcer disease status post vagotomy and antrectomy with Billroth II anastomosis and dumping syndrome. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Vemulapalli, 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.