ADJUSTMENT DISORDER WITH ANXIETY AND DEPRESSION

Summary

The Veteran served on active duty in the U.S. military from February 1993 to August 1995. The Veteran appeals the denial of service connection for an acquired psychiatric disorder, having previously had claims for PTSD, anxiety, and bipolar disorder denied in June 2014. The Board reconsidered the claim on the merits because VA received service treatment records in December 2015 that were not initially associated with the claims file. The Veteran's service treatment records indicated a diagnosis of an acquired psychiatric disorder shortly before separation, although the Veteran denied such history upon entry. A VA examination in August 2016 concluded the Veteran's symptoms were best accounted for by a personality disorder, which is non-compensable. However, the Board found this opinion had low probative value, noting it was inconsistent with the service treatment records, the separation physical, Social Security disability evaluations, and subsequent VA treatment records, which either did not mention a personality disorder or mentioned it alongside a compensable acquired psychiatric disorder. The Board assigned higher probative value to the contemporaneous service records and subsequent treatment history. While the Board could not definitively distinguish between a personality disorder and an acquired psychiatric disorder, it found the evidence approximately balanced. Applying the benefit of the doubt, the Board granted service connection for an acquired psychiatric disorder.

Rationale

Service treatment records show diagnosis of acquired psychiatric disorder in service; Separation physical noted adjustment disorder and depressed mood; Benefit of the doubt applied due to approximately balanced evidence

Full Decision Text

Citation Nr: 23022041
Decision Date: 04/11/23	Archive Date: 04/11/23

DOCKET NO. 18-02 671
DATE: April 11, 2023

ORDER

Entitlement to service connection for an acquired psychiatric disorder is granted.

FINDING OF FACT

1. The most probative evidence of record shows that the Veteran has an acquired psychiatric disorder that is related to his service.

CONCLUSION OF LAW

1. The criteria for establishing service connection for an acquired psychiatric disorder are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from February 1993 to August 1995. 

This matter comes before the Board of Veterans Appeals (Board) on appeal from an October 2016 rating decision by a VA Agency of Original Jurisdiction (AOJ). The Veteran timely perfected an appeal. See November 2016 Notice of Disagreement; December 2017 Statement of the Case; January 2018 VA Form 9.

The Board notes that a claim of entitlement to service connection for PTSD, anxiety, and bipolar disorder was previously denied in June 2014. The Veteran did not appeal this decision and it became final. 38 U.S.C. § 7105. Thus, the Board would first have to determine if VA received new and material evidence to warrant reopening the Veteran's claim of entitlement to service connection for PTSD, anxiety, and bipolar disorder. There is an exception to the finality of a rating decision denying service connection for a disability. At any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed but were not associated with the claims file when VA first decided the claim, VA will reconsider the claim, rather than requiring new and material evidence. 38 C.F.R. § 3.156 (c)(1). In this instance, the RO received service treatment records in December 2015, which had not been associated with the claims file at the time of the prior decision. Therefore, the Board will reconsider the Veteran's claim on the merits rather than determining if new and material evidence has been submitted. Id.

Acquired psychiatric disorder, to include anxiety disorder with major depressive disorder; PTSD; and bipolar disorder.

A.	Legal Criteria

Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a).

Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § § 3.303. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § § 1113(b); 38 C.F.R. § § 3.303 (d).

The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.

Personality disorders are not diseases or injuries within the meaning of the applicable legislation for VA compensation purposes. 38 C.F.R. §§ 3.303 (c), 4.9, 4.127; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). Although a personality disorder may be capable of progression, it is excluded
 be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.

Personality disorders are not diseases or injuries within the meaning of the applicable legislation for VA compensation purposes. 38 C.F.R. §§ 3.303 (c), 4.9, 4.127; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). Although a personality disorder may be capable of progression, it is excluded from service connection as non-compensable. See O'Bryan v. McDonald, 771 F.3d 1376, 1380-81 (Fed. Cir. 2014). In any such case, the presumption of soundness would not apply. See Morris v. Shinseki, 678 F.3d 1346, 1354-56 (Fed. Cir. 2012).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b). This benefit-of-the-doubt rule applies if the competing evidence is nearly equal but does not apply when the evidence persuasively favors one side or the other. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

B.	Factual Background & Analysis

The Veteran contends that he has a currently diagnosed acquired psychiatric disorder is related to his service.

As an initial matter, a VA treatment records show that the Veteran has been diagnosed with an acquired psychiatric disorder. See January 2016 CAPRI at 1-5. As such, the Board finds the current disability element is established. See Shedden v. Principi, 381 F.3d 1163, 1167.

Turning to the question of in-service injury or illness, in his report of medical history on entry to active duty, the Veteran affirmatively denied a history of these conditions. See STR, page 29-30. 

Shortly before separation from active duty, the Veteran was hospitalized for mental health stabilization at Eglin Air Force Base. Id at 21-25. At discharge from the hospital, he was diagnosed under the DSM-IV with an Axis I condition (adjustment disorder with anxiety and depression) and an Axis II condition (narcissistic and histrionic personality traits.) The Board observes that the Axis I diagnosis is an acquired psychiatric condition, and the Axis II diagnosis is a personality condition. On discharge from active duty, the Veteran was afforded a physical examination, which noted adjustment disorder and depressed mood. Id at 27. The separation physical did not note a personality disorder. Id.

Thus, the Board is persuaded that the Veteran had symptoms of and was diagnosed with an acquired psychiatric disorder in service. Accordingly, the second Shedden element is satisfied. See Shedden, supra.

Turning to the third Shedden element, nexus, VA treatment records show diagnosis and treatment for an acquired psychiatric disorder from June 2014. See November 2017 CAPRI at 338-341. A mental health treatment record from July 2014 shows a multi-axis diagnosis similar to the diagnosis in the Veteran's service treatment records, consisting of bipolar disorder not otherwise specified with suicidal ideation; and personality disorder not otherwise specified. See July 2014 CAPRI at 2. Other than the July 2014 entry, the Veteran's VA health record, which contains many mental health related entries, is silent regarding personality disorder.

Medical records furnished by the Social Security Administration show that after evaluation for Social Security disability purposes, the Veteran was diagnosed with acquired psychiatric disorders but not a personality disorder. See October 2018 Medical Treatment Records - Furnished by SSA at 47.

The Veteran was afforded a VA examination to determine the nature and etiology of his acquired psychiatric disorder. See August 2016 C&P Exam. The examiner reviewed the claims file and examined the Veteran. Id at 2. The examiner did not diagnose the Veteran with an acquired psychiatric disorder, and instead opined as follows:

"CURRENT SYMPTOMS ARE BEST ACCOUNTED FOR BY DIAGNOSIS OF UNSPECIFIED PERSONALITY DISODER WITH FEATURES OF NARCISSISTIC, HISTRIONIC, AND BORDERLINE TRAITS. MALADAPTIVE PERSONALITY TRAITS WERE EVIDENT DURING CURRENT INTERVIEW AND WERE ALSO DOCUMENTED IN DISCHARGE SUMMARY FROM PSYCH ADMISSION DURING SERVICE IN 1995.THESE PERSONALITY
 of his acquired psychiatric disorder. See August 2016 C&P Exam. The examiner reviewed the claims file and examined the Veteran. Id at 2. The examiner did not diagnose the Veteran with an acquired psychiatric disorder, and instead opined as follows:

"CURRENT SYMPTOMS ARE BEST ACCOUNTED FOR BY DIAGNOSIS OF UNSPECIFIED PERSONALITY DISODER WITH FEATURES OF NARCISSISTIC, HISTRIONIC, AND BORDERLINE TRAITS. MALADAPTIVE PERSONALITY TRAITS WERE EVIDENT DURING CURRENT INTERVIEW AND WERE ALSO DOCUMENTED IN DISCHARGE SUMMARY FROM PSYCH ADMISSION DURING SERVICE IN 1995.THESE PERSONALITY TRAITS LIKELY IMPACT HIS ABILITY TO COPE WITH STRESS AND MANGE EMOTIONS WHICH LEAVES HIM MORE VULNERABLE TO DEVELOP PSYCHOLOGICAL DIFFICULTIES (I.E. ANXIETY, DEPRESSION) DURING TIMES OF STRESS. MOREOVER, IT IS LIKELY THAT THESE PERSONALITY TRAITS WOULD EXACERBATE ANXIETY, INTERPERSONAL DIFFICULTIES, AND IRRITABILITY/ANGER THAT ARE CHARACTERISTIC OF PTSD." Id at 1.

The examiner indicated that the Veteran experiences depressed mood, anxiety, suspiciousness, and panic attacks. Id at 10. The examiner also indicated that the Veteran experiences occupational and social impairment as a result of his condition. Id at 1-2.  The examiner diagnosed the Veteran with a unspecified personality disorder, with prominent cluster B traits. As noted above, personality disorders are non-compensable for VA disability purposes. 

The Board observes that because the Veteran was diagnosed with an acquired psychiatric disorder as well as a personality condition in service, the Board's nexus inquiry in this case turns on whether the most probative medical evidence shows that the Veteran's disabling symptoms are best categorized as a personality disorder or an acquired psychiatric disorder, as there is evidence of record pointing to both.

The Board observes that the August 2016 examiner is the only medical professional of record to diagnose the Veteran only with a personality disorder. Even the service treatment records the examiner cites to indicate both an acquired psychiatric disorder and a personality condition. See STR - Medical at 21-25. Importantly, on separation from active duty, only the acquired psychiatric disorders were noted (not a personality disorder). Id at 27. The Board assigns these records high probative value because, unlike later medical opinions which attempt to look in hindsight to the origin of the Veteran's condition, these records were taken contemporaneously with the Veteran's first documented reports of an acquired psychiatric condition or personality condition. The Board notes and finds highly probative the physician's choice of the words "personality traits" on Axis II (not "personality disorders") and the conspicuous absence of a personality diagnosis entirely from the Veteran's separation physical. See STR- Medical at21-25. The Board finds that this record simply does not say what the August 2016 VA examiner summarizes, i.e., that the Veteran suffers only from a personality disorder. Rather, this record shows the opposite: a firm diagnosis of an acquired psychiatric disorder that persisted through discharge, and the suggestion of a personality condition or traits short of a firm and persistent diagnosis.

Additionally, the Board finds the conclusion of the August 2016 VA examiner inconsistent with the diagnosis the Veteran received during evaluation for Social Security disability purposes, as well as the Veteran's VA treatment records. The former makes no mention of personality disorder at all. See Medical Treatment Records - Furnished by SSA at 47. The VA treatment records only mentions personality disorder once, without lengthy discussion, together with an acquired psychiatric disorder, and does not exclusively attribute the Veteran's symptoms exclusively to personality disorder. The Board therefore assigns the August 2016 VA examination low probative value because it does not evidence thorough review of the Veteran's service treatment records, much less the rest of his medical history, in rendering its conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. At 304 (2008) ("[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion ... that contributes probative value to a medical opinion"). The Board finds the Veteran's in-service diagnosis, separation physical, Social Security records, and VA treatment records more persuasive and assigns them higher probative value.

While the Board cannot with medical certainty determine whether the Veteran's disabling condition is a personality condition or an acquired psychiatric condition, the Board finds the medical evidence at least approximately balanced. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds the third Shedden element, nexus, satisfied. 38 U.S.C. § 5107(b); See Lynch v. McDonough, 21 F.4th 776 (
8) ("[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion ... that contributes probative value to a medical opinion"). The Board finds the Veteran's in-service diagnosis, separation physical, Social Security records, and VA treatment records more persuasive and assigns them higher probative value.

While the Board cannot with medical certainty determine whether the Veteran's disabling condition is a personality condition or an acquired psychiatric condition, the Board finds the medical evidence at least approximately balanced. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds the third Shedden element, nexus, satisfied. 38 U.S.C. § 5107(b); See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Accordingly, the Veteran's claim for entitlement to service connection for an acquired psychiatric disorder is granted.  

 

R. Costello

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Divis, Robert A.

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.