Citation Nr: 23046554 Decision Date: 08/22/23 Archive Date: 08/22/23 DOCKET NO. 17-46 447 DATE: August 22, 2023 ORDER Service connection for an acquired psychiatric disorder is denied. FINDING OF FACT An acquired psychiatric disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder have not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1975 to January 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in July 2017 by a Department of Veterans Affairs (VA) Regional Office. In August 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In January 2022, May 2022, and January 2023, the Board remanded the case for additional development and it now returns for further appellate review. Entitlement to service connection for an acquired psychiatric disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 408, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). For posttraumatic stress disorder (PTSD), service connection requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). When a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5); Patton v. West, 12 Vet. App. 272, 277 (1999). Examples of such evidence include, but are not limited to, records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to, a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. Personality disorders are not "diseases" for which service connection can be granted, and as a "matter of law" are not compensable disabilities. 38 C.F.R. § 3.303(c); Beno v. Principi, 3 Vet. App. 439, 441 (1992). However, a disability resulting from a mental disorder superimposed upon a personality disorder may be service-connected. 38 C.F.R. § 4.127. The provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a mental disorder conform to the American Psychiatric Association's Diagnostic and Statistical Manual, Fifth Edition (DSM-5). See also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). The Veteran contends he has an acquired psychiatric disorder that is directly related to his military service as a result of the stress of his active duty assignments, and discrimination and harassment from superiors. However, based upon a review of the evidence, the Board finds that service connection for an acquired psychiatric disorder is not warranted. In this regard, the Veteran's service treatment records (STRs) and service personnel records (SPRs) reveal that, in March 1976, he was counseled in regard to the fact that his hair style did not meet military standards, and his unbecoming and irresponsible military bearing and behavior. In April 1976, he was removed from promotion consideration and was apprehended by the British civil police for allegedly having cannabis in his possession. In May 1976, the Veteran was counseled for his unbecoming emotional stability and advised that, while in the military, he may receive many orders he did not like. He was also counseled for his need to know, and the need to maintain the military standards of dress and appearance. The Veteran was arrested in May 1976 and June 1976 for cannabis possession and verbally admitted to use of such drug prior to entering the military. In June 1976, he was placed on the control roster for abuse of drugs and was counseled on his responsibilities in regard to the standards/personal appearance the Air force required him to maintain. Additionally, in July 1976, the Veteran was recommended for a psychological evaluation to determine his fitness for continued military duty as he was identified as a drug abuser in regard to cannabis use, and was presently in phase 5 of the social actions rehabilitation program. He appeared to be experiencing difficulties in accepting the adult responsibilities expected of a military member. His July 1976 psychological evaluation noted that he may be slightly immature, but appeared to possess slightly above average intelligence and, with a bit more maturity, he should be psychologically fit for military duty. However, at present, he did not seem to have reached that stage. In July 1976, the Veteran stated that he wanted to stay in the Air Force, but he was not trained in the area for which he was enlisted. He also stated that his supervisor was always harassing everyone about military standards and minor things, but he now conformed to such standards and did not appear resentful. A contemporaneous examination revealed that the Veteran had a normal psychiatric clinical evaluation, and the clinician noted he had no mental defects to warrant separation under the provisions of Air Force Manual 35-4. In December 2009, the Veteran was afforded a VA examination, at which time he was diagnosed with cocaine dependence and depressive disorder not otherwise specified (NOS). The examiner opined that the Veteran's depression was less likely as not caused by or a result of his service. In support thereof, he highlighted the absence of actual mental health treatment in service and found it significant that the recent treatment records noted the Veteran's depression was related to ongoing cocaine abuse, which began long after service. In addition, the VA examiner noted that the most recent treatment of any type was approximately four years previously. However, he did not have the opportunity to review the Veteran's SPRs, which were not of record at the time of such examination. Thus, in May 2018, the Veteran underwent another VA examination, at which time the examiner found that his symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria, but he had diagnoses of cyclothymic disorder and narcicisstic personality disorder. She opined that such disorders were less likely as not caused by or a result of an in-service event. In this regard, she explained that the onset and maintenance of the symptoms of the current disorders could not be triggered or explained by the Veteran's reported in-service events. In addition, the VA examiner noted his denial of any incidents of physical altercations, assault, or sexual abuse during service, and thus opined no nexus could be established. Specifically, she found that the personal assault stressors described by the Veteran were not supported by in-service marker evidence. In this regard, the VA examiner noted that the official documents showed the Veteran's noncompliance with the military's specific rules and regulations, and the suggested changes in behavior. Thus, she found that the Veteran's description of the stressors could not be qualified as a personal assault or traumatic event from a clinical point of view. However, the examiner did not address all acquired psychiatric disorders diagnosed during the pendency of the appeal, and did not have the opportunity to address the findings in a February 2017 private diagnostic assessment that was subsequently received in June 2018. Specifically, in such assessment, a private physician, S.L., determined that a clinical interview and psychometrics confirmed the Veteran's previous diagnosis of bipolar I disorder and reflected indicators of PTSD, which had been previously denied and not diagnosed. Specifically, he found the Veteran met the DSM markers for Criteria A and B. S.L. diagnosed bipolar I disorder and PTSD, and "recommend[ed] reconsideration" of service connection for the Veteran's mental health issues. Nonetheless, such assessment did not contain a clear opinion relating a current psychiatric disorder to service, and the Board finds the lack of specificity therein, to include with respect to whether the full criteria for a diagnosis of PTSD have been met and the identification of specific in-service stressors, is insufficient to support a finding of service connection. Thus, such is afforded no probative weight. Consequently, the Veteran was afforded another VA examination in February 2022. At such time, the VA examiner clarified that the Veteran's current acquired psychiatric disorders were cyclothymic disorder and narcissistic personality disorder as no other mental health diagnosis was added. In this regard, she explained that, according to the Veteran, he was diagnosed with bipolar disorder in 2005, during a chemical dependency treatment at VA. The examiner noted that he was also in treatment for active use of cocaine and alcohol, and a diagnosis of bipolar disorder during the active use of mood-altering substances is of questionable validity. Specifically, she explained that a July 2009 mental health note indicated the Veteran's diagnoses as cocaine dependence and substance induced mood disorder, the latter of which was more appropriate for a person in a treatment for chemical dependency problems. The examiner noted that a diagnosis of bipolar disorder stayed as one of the Veteran's problems based on his report of history, unstable mood, anger problems, and episodes of depression. However, he had never been hospitalized for manic episodes or severe depression, and he was not observed having a manic or hypomanic episode, even when he described his mood as manic during psychiatric appointments. Additionally, the examiner reasoned that a large number of substances of abuse can be associated with manic-like phenomena and the Veteran was diagnosed with bipolar disorder, current episode manic without psychotic features, moderate, by Dr. S.L. in February 2017. However, he did not describe any manic symptoms during the assessment. Thus, the examiner reasoned that the Veteran's description of the severity of his current manic/hypomanic episodes followed by depressed mood was consistent with the DSM-5 criteria for cyclothymic disorder, which falls into the category of bipolar and related disorders. With regard to the Veteran's diagnoses of major depressive disorder and depressive disorder NOS that were indicated in his treatment records, the examiner explained that, based on the Veteran's presentation and his description of emotional problems during his May 2018 VA examination, his episodes of depression appeared to be a part of mood swings under a diagnosis of cyclothymic disorder. In regard to the Veteran's diagnosis of narcissistic personality disorder, she noted that such was based on his medical records regarding his lack of respect, personal misconduct, disregard of authorities and discipline, his tendency to blame others for his own failures, and the results of the Millon Clinical Multiaxial Inventory III. Thus, the examiner opined that the Veteran suffered from cyclothymic disorder, which explained his mood swings, including depressive episodes, and narcissistic personality disorder. Specifically, she reasoned that it was necessary to take into consideration the Veteran's long-standing history of chemical dependency problems and, during his active use, such had significant impact on his emotional functioning and stability. The examiner also found that the Veteran did not meet the DSM 5 criteria for PTSD as his stressors of being discriminated and/or harassed during service could not be classified as Criterion A necessary for such diagnosis. With regard to Dr. S.L.'s PTSD diagnosis in February 2017, she explained that he did not have the Veteran's service department records that clearly described his personal misconduct, unsatisfactory behavior, lack of self-discipline, lack of respect and understanding for basic responsibilities, immaturity, and cynical attitude. The examiner also noted that Dr. S.L. did not explore the true nature of the Veteran's reported stressors/trauma that led to his problems, although he mentioned that "one notable aspect of this dialog (the Veteran's description of his difficulties in the military) was the fact that he (the Veteran) took little if any ownership for the consequences of his behavior." Thus, the examiner concluded that the Veteran suffered from cyclothymic disorder and narcissistic personality disorder, which he likely developed independently of his military service. Therefore, the examiner opined that the Veteran's cyclothymic disorder and narcissistic personality disorder were less likely than not incurred in or caused by his military service. Additionally, she noted that the Veteran's contentions that unfair treatment and harassment during his military service caused his mental health problems, but his service department records showed his personal misconduct, lack of self-discipline, lack of respect for basic responsibilities, unsatisfactory behavior, and dereliction of duty. The examiner also observed there was no indication in the Veteran's records of any traumatic experiences/incidents, physical or sexual abuse, and he did not report any traumatic experiences that could explain the described behaviors. Thus, she concluded that the Veteran's emotional problems were less likely than not incurred in or caused by his military service. Nonetheless, while the VA examiner diagnosed the Veteran with a personality disorder, i.e., narcissistic personality disorder, she did not provide an opinion as to whether it was at least as likely as not that such disorder was subject to a superimposed disease or injury during service that resulted in an additional psychiatric disorder, to include cyclothymic disorder. Accordingly, an addendum opinion was obtained in June 2022. However, such examiner did not provide an opinion on such matter. Rather, she addressed whether the Veteran met the DSM-5 criteria for PTSD, whether his cyclothymic disorder and narcissistic personality disorder were incurred in or caused by his military service, and whether his cyclothymic disorder was caused by his narcissistic personality disorder. In this regard, the examiner explained that the only document that mentioned a diagnosis of PTSD was the February 2017 assessment from Dr. S.L., but that he did not give a detailed description of the traumatic events reported by the Veteran or indicate the specific symptoms of PTSD. Additionally, she noted the May 2018 examination found that the Veteran did not meet the DSM-5 criteria for PTSD as his description of military traumatic events did not meet the Criterion A for PTSD. The examiner also noted that disciplinary actions that were taken in response to the Veteran's behavior during service did not meet Criterion A and his service department records did not have information of his mental health problems or psychiatric treatment during military service. She further noted that the nature and development of the cyclothymic disorder and narcissistic personality disorder did not indicate that the Veteran's miliary service played a significant role in the onset of these conditions. Thus, she concluded the Veteran did not meet the DSM-5 criteria for PTSD, and his cyclothymic disorder and narcicisstic personality disorder were less likely than not incurred in or caused by his military service. Additionally, as pertinent to the relationship between the Veteran's narcissistic personality and his cyclothymic disorder, the examiner explained that genetics and neurobiology play a significant role in the development of both disorders, and most medical experts consider that both conditions occur separately. She further stated that the Veteran's narcissistic personality disorder could not cause cyclothymic disorder or any other psychiatric disorder. Thus, she concluded the Veteran's cyclothymic disorder was less likely than not caused by his narcissistic personality disorder. Pursuant to the January 2023 remand, an addendum opinion was obtained in February 2023 to address whether it was at least as likely as not that the Veteran's currently diagnosed narcissistic personality disorder was subject to a superimposed disease or injury during service that resulted in an additional psychiatric disorder, to include cyclothymic disorder. At such time, the same examiner again noted that the Veteran had been diagnosed with cyclothymic disorder and narcissistic personality disorder, which were less likely than not incurred in or caused by his military service, and his cyclothymic disorder was less likely than not caused by his narcicisstic personality disorder. As relevant, she noted that a thorough review of the record revealed that the Veteran was not subjected to any disease or injury during service that resulted in an additional psychiatric disorder, including cyclothymic disorder. In this regard, she noted that there was no evidence that the Veteran's currently diagnosed narcissistic personality disorder was subject to a superimposed disease or injury during service that resulted in cyclothymic disorder. Thus, she concluded the Veteran's narcissistic personality disorder was less likely than not proximately due to or the result of a superimposed disease or injury during service that resulted in cyclothymic disorder. She also concluded that the Veteran did not develop cyclothymic disorder as a result of a disease or injury that was superimposed on his narcissistic personality disorder. In this regard, the examiner explained that the medical literature, including the DSM-5, indicated that narcissistic personality disorder and cyclothymic disorder are two distinct and separate mental health diagnoses that have different etiology and developmental course. She also noted that they have a few overlapping features and are frequently comorbid with each other, but narcissistic personality disorder does not cause the onset of cyclothymic disorder and cyclothymic disorder does not result in narcissistic personality disorder. She further explained that the Veteran's difficulties during his military service, such as disciplinary actions, could not be classified as a disease or injury during service. Additionally, in June 2023, a letter dated in March 2022 was received from Dr. T.S., the Veteran's private psychiatrist. He noted that during the Veteran's initial consultation, he reported that he had been diagnosed with Bipolar I disorder and PTSD. Dr. T.S. noted that he had reviewed outside records, including the February 2017 assessment from Dr. S.L., and noted his diagnostic impression from the Veteran's most recent visit in September 2021 were mood disorder, delayed sleep-wake phase disorder, other specified trauma and stressor related disorder, and delayed sleep wake phase disorder. In this regard, he noted the Veteran had chronic symptoms, including depressive symptoms, difficulty controlling anger, and insomnia. Dr. T.S. indicated that he had generally formulated such as PTSD and personality traits. He found that the Veteran's mood diagnosis was mood disorder as he had not observed or obtained history of clear patterns of bipolar disorder, but recognized he was diagnosed with bipolar elsewhere. With regard to the PTSD diagnostic criteria, Dr. T.S. noted that the Veteran appeared to meet most criteria, but was less clear on the criteria for traumatic events exposure to actual or threatened death, serious injury, or sexual violence, though he described his maltreatment during service. The Veteran also reported that, at one point, he was physically threatened by a peer that he found was highly distressing. Nonetheless, as Dr. T.S. did not offer an opinion as to whether the Veteran's currently diagnosed acquired psychiatric disorder was related to his military service, such letter is afforded no probative weight. Upon review, the Board affords great probative weight to the February 2022, June 2022, and February 2023 VA opinions. In this regard, the opinions proffered considered all the pertinent evidence of record, to include the Veteran's statements and his relevant military and medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Additionally, as indicated previously, the Board accords no probative weight to the diagnoses of PTSD from the Veteran's private treatment providers as such diagnoses are conclusory and did not identify how each criterion necessary for such a diagnosis were met. The Board observes that, if a veteran has received a diagnosis of PTSD from a competent medical professional, VA must assume that the diagnosis was made in accordance with the appropriate psychiatric criteria in regard to the adequacy of the symptomatology and the sufficiency of the stressor. Cohen v. Brown, 10 Vet. App. 128, 153 (1997). VA can only reject such a diagnosis on a finding that the preponderance of the evidence is against (1) the PTSD diagnosis, (2) the occurrence of the in-service stressor, or (3) the connection of the current condition to the in-service stressor. The adequacy of a stressor, sufficiency of symptomatology, and diagnosis are all medical determinations. Cohen, 143-44. In the instant case, the Board finds that the PTSD diagnoses include only a brief discussion of the Veteran's psychological status and/or a conclusory finding of a PTSD diagnosis without a complete discussion of how each criterion was met. In this regard, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Furthermore, the February 2022 examiner explained that the Veteran did not have a diagnosis of PTSD as his stressors of being discriminated and/or harassed during service could not be classified as Criterion A necessary for such diagnosis. Moreover, with regard to the Veteran's currently diagnosed narcissistic personality disorder, as noted previously, personality disorders are not "diseases" or "injuries" for which service connection can be granted as a matter of law. 38 C.F.R. §§ 3.303 (c), 4.9; Beno, supra. Consequently, service connection for the Veteran's narcissistic personality disorder is precluded by law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law and not the evidence is dispositive of the issue before the Board, the claim should be denied because of the lack of legal merit or the lack of entitlement under the law). Additionally, the February 2023 examiner explained that the Veteran's narcissistic personality disorder was not subjected to a superimposed disease or injury during service that resulted in an additional psychiatric disorder, to include cyclothymic disorder. Additionally, the Board notes that the Veteran's representative argued that an adequate opinion had not been obtained to determine whether the Veteran's acquired psychiatric disorder, other than PTSD, is related to his military service as he did not have a family history of cyclothymic disorder or a diagnosis of neurobiological condition that could explain the lack of nexus to his military service, and no examiner had identified the etiology of such disorders. However, as previously noted, the VA opinions obtained in February 2022, June 2022, and February 2023 fully addressed the relationship between the Veteran's diagnosed acquired psychiatric disorders and his military service, which is the crux of the matter at issue in this case. In this regard, there is no duty on VA to identify the specific etiology of a disorder if unrelated to military service. Moreover, the United States Court of Appeals for Veterans Claims has held that a VA opinion report is adequate if it is based on correct facts and sufficiently informs the Board of the medical expert's judgment on a medical question and the "essential rationale" for the opinion. Monzingo v. Shinseki, 26 Vet. App. 97, 105-7 (2012); Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that VA examiners do not have a reasons or bases requirement). Thus, the Board finds the Veteran's representative argument without merit, and no further development is necessary. Furthermore, the Board notes that, in November 2022, the Veteran's representative cited to a medical article discussing cyclothymia symptoms and causes. However, such is not accompanied by any corresponding clinical evidence specific to the Veteran and do not suggest a generic relationship between his acquired psychiatric disorder and his military service with a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Consequently, such article is not probative to the instant matter and, therefore, is insufficient to grant the Veteran's claim. Wallin v. West, 11 Vet. App. 509 (1998); Sacks v. West, 11 Vet. App. 314 (1998); Libertine v. Brown, 9 Vet. App. 521 (1996). The Board has also considered the Veteran's assertions that he has a diagnosis of an acquired psychiatric disorder related to his military service; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of an acquired psychiatric disorder involves a medical subject concerning an internal psychiatric process extending beyond an immediately observable cause-and-effect relationship. Specifically, the diagnosis and etiology of such a disorder requires the applicability of DSM-5, as well as knowledge of the impact traumatic experiences have on the human psyche. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran's opinion as to the diagnosis and etiology of his claimed acquired psychiatric disorder is not competent evidence and, consequently, is afforded no probative weight. Therefore, the Board finds that an acquired psychiatric disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. Thus, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against the Veteran's claim for service connection for an acquired psychiatric disorder, such doctrine is not applicable in the instant appeal and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Clark 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.