POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The Veteran served from August 1984 to May 1987. He appeals the denial of service connection for Posttraumatic Stress Disorder (PTSD). The Board previously declined service connection, but a Joint Motion for Remand (JMR) from the Court of Appeals for Veterans Claims (CAVC) led to this review. The Veteran contends he has a current PTSD diagnosis due to his service, citing a confrontation in July 1986 and subsequent mental health treatment. Service connection for PTSD requires a DSM-V diagnosis, credible evidence of an in-service stressor, and a medical nexus. The Veteran's service treatment records from 1985 noted questionable judgment but no diagnosis. He received various diagnoses, including bipolar disorder, before a September 2016 diagnosis of PTSD, which appeared in treatment notes after he inquired about a PTSD program. The Board weighed conflicting medical opinions, giving greater weight to a August 2017 VA psychiatric examination. This examination found no PTSD diagnosis, citing the Veteran's treatment history, substance abuse, and other psychiatric disorders, while discounting PTSD. The Board found this opinion more probative due to its comprehensive review of the entire case file and detailed rationale. Opinions from private providers C.M., LMHC, and J.S., LCSW, were given less weight due to limited access to the Veteran's history and case file. The Board concluded the Veteran does not have a current DSM-V diagnosis of PTSD related to military service, and the preponderance of the evidence is against the claim. Service connection for PTSD is denied.

Rationale

VA examiner found no current DSM-V diagnosis of PTSD; VA opinion favored due to comprehensive review of case file; Private provider opinions given less weight due to limited access

Full Decision Text

Citation Nr: 20071084
Decision Date: 11/04/20	Archive Date: 11/04/20

DOCKET NO. 19-04 343
DATE: November 4, 2020

ORDER

Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied.

FINDING OF FACT

The Veteran does not have a current PTSD disability that is related to his active duty service.

CONCLUSION OF LAW

The criteria for entitlement to service connection for PTSD have not all been met. 38 U.S.C. §§ 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active duty service from August 1984 to May 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the October 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), denying the Veteran’s claim for service connection for PTSD. 

In an October 2019 decision, the Board declined to grant service connection for PTSD.

A June 2020 Court of Appeals for Veterans Claims (CAVC) order vacated the Board's decision and adopted a Joint Motion for Remand (JMR) for the Veteran's claim regarding PTSD. This issue is once again before the Board.

1. Entitlement to service connection for posttraumatic stress disorder (PTSD)

The Veteran contends he has a current PTSD disability that is due to his active service. 

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. § 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) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (the DSM-V) criteria, in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304(f)(3); Cohen v. Brown, 10 Vet. App. 128, 139 (1997).

As the Veteran does not allege, and the record does not support, stressors related to combat with the enemy, the Veteran's lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran's testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996).

If 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).

Effective August 4, 2014, the VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to Diagnostic and Statistical Manual, 4th Edition (DSM-IV) and replacing them with references to the DSM-V. As the Veteran submitted his claim of service connection for PTSD in April 2017, the DSM-V applies. See 38 C.F.R. § 3.304(f)(2); Molitor v. Shulkin, 28 Vet. App. 397, 410-11 (2017).

Previously, the Board declined to grant service connection, finding that the Veteran did not have a current PTSD diagnosis consistent with DSM-V criteria. The Board again finds insufficient evidence of a current DSM-V diagnosis. A review of his treatment history and the Board’s reasoning follows.

The Veteran’s medical record reflects multiple periods of mental health treatment and varying diagnoses. His service treatment records (STRs) contain a mental health evaluation from November 1985 reflecting questionable judgment,
 his claim of service connection for PTSD in April 2017, the DSM-V applies. See 38 C.F.R. § 3.304(f)(2); Molitor v. Shulkin, 28 Vet. App. 397, 410-11 (2017).

Previously, the Board declined to grant service connection, finding that the Veteran did not have a current PTSD diagnosis consistent with DSM-V criteria. The Board again finds insufficient evidence of a current DSM-V diagnosis. A review of his treatment history and the Board’s reasoning follows.

The Veteran’s medical record reflects multiple periods of mental health treatment and varying diagnoses. His service treatment records (STRs) contain a mental health evaluation from November 1985 reflecting questionable judgment, but no clinical diagnosis. The Veteran testified at his March 2019 hearing that he was targeted by his chain of command after a confrontation in July 1986. His May 1987 military recommendation for discharge stated that the Veteran underwent mental health treatment in June and November 1985, in July 1986, and from July 1986 to January 1987, this time for substance abuse. His treatment notes from July 1986 state that he did not have a history of substance abuse on referral to the program. Rather, he had been referred in response to a single incident. That counselor reviewed the November 1985 evaluation, restating that the Veteran had no mental health diagnoses, only “rebelliousness” in his attitude. 

The first mental health treatment record addressing PTSD appears in September 2002. That note stated that the Veteran tested positively for PTSD on a brief screen, but did not include PTSD in his list of clinical diagnoses. The Veteran tested negatively for PTSD in November 2002, February 2006, February 2007, and September 2012. He was diagnosed with bipolar disorder type II in June 2008 and then with type I in August 2008. 

Bipolar disorder remained his primary diagnosis until September 2016, when he was diagnosed with PTSD, listed as a DSM-V diagnosis. Treatment notes reflect that on September 6, 2016, the Veteran engaged in therapy with a VA psychiatrist, for regularly-scheduled treatment of bipolar disorder. His psychiatric diagnoses were listed on his treatment notes as bipolar disorder I and cocaine use disorder in early full remission, with a history of alcohol use, cluster B traits, and ADHD. On September 13, 2016, the Veteran returned for treatment. Notes reflect that he inquired into PTSD program based on his symptoms. It was noted that he experienced nightmares and had been unable to take medication for them due to a reaction to the medication. At the end of this treatment note, PTSD appears in the Veteran’s list of diagnoses. 

VA treatment notes from September 14 to 20 contain follow up calls with the Veteran and a letter recommending him for inpatient treatment in a PTSD treatment program. In October, there was a telephone confirmation of the PTSD diagnosis from one physician to another and the Veteran was admitted for inpatient PTSD treatment. The Board reviewed treatment notes from his inpatient stay from December 2016 through late February 2017. In April 2017, the Veteran completed a CAPS diagnostic screen for PTSD in accordance with the DSM-5.

In August 2017, the Veteran underwent a VA psychiatric examination. At that time, the examiner determined that he did not meet the required DSM-V criteria for PTSD. Also in August 2017, the VA treating physician submitted a statement that the Veteran had been diagnosed with PTSD and was in treatment for the same. The record shows this physician expanded this statement to include a longer list of symptoms, submitted in November 2017. The Veteran also submitted a November 2017 assessment by provider C.M., LMHC, who concluded that the Veteran met all criteria to diagnose PTSD. She reviewed the Veteran’s symptoms of anger, depression, and intrusive thoughts. From November 2017 forward, the Veteran’s VA medical records generally note PTSD on his list of current diagnoses. 

In December 2018, the Veteran submitted a statement from Dr. D.L.F., his marriage counselor, who acknowledged the Veteran’s PTSD as diagnosed by other providers. In June 2018, the Veteran submitted from J.S., LCSW, who stated that she had worked with the Veteran for one week, from 24 May to 1 June 2018, and had diagnosed him with PTSD in accordance with the DSM-V. In March 2019, the Veteran submitted a second C.M. statement that she had treated the Veteran “over the past few years.” She listed the DSM-V criteria and reiterated the Veteran’s PTSD diagnosis. 

As such, the Board must weigh the probative value of conflicting medical opinions regarding the Veteran’s diagnosis. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the
, who acknowledged the Veteran’s PTSD as diagnosed by other providers. In June 2018, the Veteran submitted from J.S., LCSW, who stated that she had worked with the Veteran for one week, from 24 May to 1 June 2018, and had diagnosed him with PTSD in accordance with the DSM-V. In March 2019, the Veteran submitted a second C.M. statement that she had treated the Veteran “over the past few years.” She listed the DSM-V criteria and reiterated the Veteran’s PTSD diagnosis. 

As such, the Board must weigh the probative value of conflicting medical opinions regarding the Veteran’s diagnosis. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits.  See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998).  Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion.  See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). 

Here, the August 2017 VA examination finding no PTSD diagnosis was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinion. Each of the DSM-V criteria are laid out and addressed for review. Additionally, the examination contains a detailed recounting of the Veteran’s treatment history, substance abuse, social history including his family life, and review of his treatment notes in the context of service connection. The examiner cites and endorses the Veteran’s other psychiatric disorders while discounting a PTSD diagnosis based on a total review of the Veteran’s medical record. 

This is the only medical opinion on record that was written with full access and review of the Veteran’s entire case file. The Board observes that Dr. D.L.F. and LCSW J.S. had comparatively limited access to both the Veteran and his history, as neither reviewed the file or did so in the context of diagnosing or treating the Veteran for PTSD. As such, the VA examiner’s opinion is given much greater weight. 

While the Board can assume the Veteran’s VA treating physician had the knowledge, skill, and familiarity with the Veteran to provide an opinion on this case, the Board finds the VA examination more probative. The treating physician provided statements that she diagnosed the Veteran with PTSD in accordance with DMS-V criteria, presumably through the CAPS assessment dated completed in October 2016. This was completed without a full review of the Veteran’s case file or access to documents outside the Veteran’s direct report. The PTSD diagnosis was only made immediately following and because he requested to participate in a program requiring that diagnosis, despite the fact that he had been in psychiatric treatment since at least 2009 and in therapy with this physician since at least August 2016 without any prior positive PTSD diagnosis. Further, her statements provide no foundation for determining that his PTSD is the result of his in-service experiences. The Board thus places more probative weight on the August 2017 VA medical opinion.

Finally, the Board finds the same applies to the Veteran’s March 2019 evidence from C.M., LMHC. As previously stated, there is no evidence that this provider reviewed the Veteran’s claim file before offering her opinion on his case or was sufficiently familiar with the documented history of the Veteran’s psychiatric condition and treatment. Her statement does not provide any evidence that he receives treatment from her, that she has read any medical records outside of her own pertaining to this claim, or provide any context for her apparent “extensive knowledge.” Notably, she does not mention or delineate symptoms of the Veteran’s other psychiatric diagnoses. The Board thus places more probative weight on the August 2017 VA medical opinion.

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The Board recognizes that the Veteran believes he has PTSD related to military service. However, whether the Veteran meets the required diagnostic criteria for PTSD is a complex medical question and is not within the realm of knowledge of a lay person or determinable by observation with one's senses. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Therefore, the Veteran's statement is not competent evidence and not
 or provide any context for her apparent “extensive knowledge.” Notably, she does not mention or delineate symptoms of the Veteran’s other psychiatric diagnoses. The Board thus places more probative weight on the August 2017 VA medical opinion.

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The Board recognizes that the Veteran believes he has PTSD related to military service. However, whether the Veteran meets the required diagnostic criteria for PTSD is a complex medical question and is not within the realm of knowledge of a lay person or determinable by observation with one's senses. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Therefore, the Veteran's statement is not competent evidence and not probative.

For the foregoing reasons, the Board concludes that the Veteran does not have a current diagnosis of PTSD related to military service. As the preponderance of the evidence is against the claim, entitlement to service connection for PTSD is denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

 

 

JAMES G. REINHART

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Department of Veterans Affairs

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.