ADJUSTMENT DISORDER

Summary

The veteran, who served in the United States Marine Corps from September 1987 to October 1990, appeals the denial of service connection for PTSD and the remand of claims for spinal bone spurring and temporomandibular joint (TMJ) syndrome. The veteran asserted a diagnosis of PTSD due to an in-service motor vehicle accident, but the Board found no medical evidence supporting a PTSD diagnosis, noting that all PTSD screenings were negative and that the Veteran's lay statements were outweighed by VA examiner findings. The Board denied entitlement to a change in diagnosis from adjustment disorder to PTSD, finding the evidence persuasively weighed against the claim. The Board remanded the claims for spinal bone spurring and TMJ syndrome for further development. For spinal bone spurring, the Board noted conflicting x-ray findings and ordered an addendum opinion to reconcile these and determine the etiology, including secondary service connection to lumbar or cervical strain. For TMJ, the Board found the VA examiner's opinions inadequate, failing to consider private medical opinions or the Veteran's testimony regarding onset and relation to service-connected adjustment disorder. The case was remanded for addendum opinions addressing direct and secondary causation for TMJ, including aggravation by adjustment disorder.

Rationale

No medical evidence supports PTSD diagnosis.; PTSD screenings were negative.; Veteran's lay statements outweighed by VA examiner findings.

Full Decision Text

Citation Nr: 24031323
Decision Date: 10/01/24	Archive Date: 10/01/24

DOCKET NO. 18-55 101
DATE: October 1, 2024

ORDER

Entitlement to a change in diagnosis/nomenclature of adjustment disorder (previously rated as anxiety disorder NOS with insomnia) to posttraumatic stress disorder (PTSD) is denied.

REMANDED

Entitlement to service connection for spinal bone spurring, to include as secondary to service-connected lumbar strain and/cervical strain, is remanded.

Entitlement to service connection for temporomandibular joint syndrome (TMJ), to include as secondary to service-connected adjustment disorder, is remanded.

FINDING OF FACT

The Veteran has not been diagnosed with PTSD at any point during the course of the appeal; thus, a change in diagnosis/nomenclature is not warranted.

CONCLUSION OF LAW

The criteria for service connection for PTSD, to include a change in diagnosis/nomenclature of the Veteran's already service-connected psychiatric disorder, are not met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Marine Corps from September 1987 to October 1990.

These issues come before the Board of Veterans' Appeals (Board) on appeal of a rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO).

In January 2022, the Veteran appeared at a Board hearing before the undersigned acting Veterans Law Judge.  The Veteran's claims file contains a copy of the hearing transcript.

In May 2023, the Board remanded this case for further development.  As discussed further below, with respect to the issue decided herein, the Board finds that there has been substantial compliance with the prior Board remand directives.  Stegall v. West, 11 Vet. App. 268, 271 (1998).   

The Board also remanded the issue of entitlement to service connection for residuals for a spinal injury, other than lumbar, for further development.  Subsequently, service connection was awarded for a cervical strain in a December 2023 rating decision; representing a full grant of the benefit sought on appeal. 

Entitlement to a change in diagnosis/nomenclature of adjustment disorder (previously rated as anxiety disorder NOS with insomnia) to PTSD 

The Veteran has asserted that he has a diagnosis of PTSD due to his inservice motor vehicle accident, and, thus, his current service-connected psychiatric disorder should be characterized as PTSD.     

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.  Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Further, service connection for PTSD has additional requirements, including medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a).  38 C.F.R. § 3.304(f).  Indeed, this requirement is not limited to PTSD, rather 38 C.F.R. § 4.125(a) and the rating schedule in § 4.130 require a mental condition to be formally diagnosed in order for compensation to be awarded.  Martinez-Bodon v. McDonough, 28 F.4d 1241 (Fed. Cir. 2022).

Based on the evidence of record, the Board finds that the evidence persuasively weighs against finding that the Veteran has had a diagnosis of PTSD at any time during the pendency of the claim or recent to the filing of the claim.  Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).  

As indicated in the prior remand, VA clinical records as well as VA examinations dated in May 2015, December 2016 and September 2020 do not show a diagnosis of PTSD based on the diagnostic criteria.  However, given the Veteran's testimony indicating that he suffered from PTSD symptoms due to the in-service motor vehicle accident, the Board remanded
 against finding that the Veteran has had a diagnosis of PTSD at any time during the pendency of the claim or recent to the filing of the claim.  Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).  

As indicated in the prior remand, VA clinical records as well as VA examinations dated in May 2015, December 2016 and September 2020 do not show a diagnosis of PTSD based on the diagnostic criteria.  However, given the Veteran's testimony indicating that he suffered from PTSD symptoms due to the in-service motor vehicle accident, the Board remanded this matter again to obtain a VA examination to determine whether the criteria for PTSD have been met.  After reviewing the record and examining the Veteran, the September 2023 VA examiner explicitly found that the Veteran did not meet the criteria for a diagnosis of PTSD.  Again, there is no medical evidence of record to refute this finding. 

The VA examiner's findings are probative, because they are based on an accurate medical history and provide a clear explanation as to why no diagnosis has been made, which is based on supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

The Board recognizes that in recent VA clinical records, the Veteran has reported that he was previously diagnosed with PTSD by the VA.  However, review of VA clinical records shows no PTSD diagnosis by a medical professional, and that all of his PTSD screenings were negative.  Thus, PTSD notations in the record are based on the Veteran's reported history.  

The Board has also carefully reviewed and considered the Veteran's statements regarding his PTSD symptoms.  The Board acknowledges that the Veteran, in advancing this appeal, believes in the merits of his appeal.  Moreover, the Veteran is competent to report observable symptoms.  Layno v. Brown, 6 Vet. App. 465 (1994).  However, he is not competent to attribute his symptoms to a specific psychiatric diagnosis as medical expertise is necessary.  As such, his statements are outweighed by the probative VA examiner's findings, which considered his statements and diagnosed with another psychiatric disorder; as well as the remaining VA examinations and VA clinical records.

As explained to the Veteran during the course of seeking treatment, he is eligible for the same mental health treatment based on his current service-connected psychiatric condition.  Moreover, all of his psychiatric symptoms are contemplated in his current disability rating.  In sum, with respect to obtaining treatment or compensation, there is no detriment to the Veteran for not being diagnosed with PTSD.    

In conclusion, based on the analysis above, the evidence persuasively weighs against finding that service connection for PTSD is warranted and, in turn, a change in the diagnosis/nomenclature of the Veteran's currently service-connected psychiatric disability is not allowed.  Again, a mental condition must be formally diagnosed in order for service connection to be awarded, and a diagnosis of PTSD is not present in the current case.  Martinez-Bodon v. McDonough, 28 F.4d 1241 (Fed. Cir. 2022).  As the evidence persuasively weighs against the Veteran's claim, the benefit-of-the-doubt standard of proof does not apply.  38 U.S.C. § 5107(b).

REASONS FOR REMAND

Initially, the Board notes that in its prior remand, the Board directed the agency of original jurisdiction (AOJ) to take steps to obtain private treatment records identified at the Board hearing.  In May 2023, the AOJ requested the Veteran to submit an authorization so that these records could be obtained.  However, to date, the Veteran has not submitted authorization for these records.  As the AOJ substantially complied with this remand directive, the Board finds that another remand to obtain these records is not necessary.  The Veteran may still submit such authorization or these records if he wants them to be considered with respect to the remaining issues.

Unfortunately, with respect to the issues of service connection for spinal bone spurring and TMJ, the Board finds that adequate medical opinions as to the nature and etiology of these disabilities were not obtained as previously directed by the Board.  Thus, while the Board regrets the additional delay, another remand is necessary to comply with the prior Board remand directives with respect to these issues.  See Stegall, supra. 

Service connection for spinal bone spurring, to include as secondary to service-connected lumbar strain and/cervical strain

This matter was remanded in order to afford the Veteran with a VA examination with etiological opinion.  The October 2023 VA examiner found that there was no evidence of bone spurring based on a
, with respect to the issues of service connection for spinal bone spurring and TMJ, the Board finds that adequate medical opinions as to the nature and etiology of these disabilities were not obtained as previously directed by the Board.  Thus, while the Board regrets the additional delay, another remand is necessary to comply with the prior Board remand directives with respect to these issues.  See Stegall, supra. 

Service connection for spinal bone spurring, to include as secondary to service-connected lumbar strain and/cervical strain

This matter was remanded in order to afford the Veteran with a VA examination with etiological opinion.  The October 2023 VA examiner found that there was no evidence of bone spurring based on a September 2023 x-ray, and thus opined that the condition was not related to service.  However, VA clinical records dated in May 2014 indicated that x-rays of the thoracic spine showed some bone spurs.  Unfortunately, the October 2023 VA examiner did not reconcile this finding with the September 2023 x-ray that showed no bone spurs.  As such, an addendum opinion is necessary to determine the etiology of any diagnosed bone spurs. 

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Service connection for TMJ, to include as secondary to service-connected adjustment disorder

This matter was also remanded for a VA examination with etiological opinion.  The October 2023 VA examiner initially found that TMJ was not related to service.  To summarize, the examiner explained that there was no diagnosis in service, and the Veteran was first diagnosed in December 2016, 26 years after service.  The examiner also appeared to rely on the lack of findings of bruxism and at one point indicated that the onset was in service.  Thus, the AOJ determined that this rationale was inadequate and addendum opinion was obtained in January 2024, which also countered the claim.  Due to deficiencies in this opinion, another addendum opinion was obtained in March 2024 to address aggravation.  The examiner again noted that TMJ was diagnosed in 2016 and essentially reiterated her prior January 2024 opinion.

Unfortunately, the Board must find that even taken together, the examiner's opinions are inadequate as the examiner failed to consider all of the relevant evidence of record and provide a detailed rationale based on such evidence.  Nieves-Rodriguez, 22 Vet. App. 295 (2008).  In this regard, the examiner did not consider the February 2022 private opinion by Dr. J.J., which found that that Veteran's TMJ began during service and remained undiagnosed until 2016.  The examiner also failed to address the Veteran's statements and hearing testimony indicating that his symptoms began during active service.  The Veteran at times has also indicated that it was related to his October 1988 in-service motor vehicle accident.  Moreover, VA clinical records show that the Veteran has been diagnosed with TMJ at least since 2011, and those records appear to indicate that he was already diagnosed with TMJ at that time. 

Further, significantly, the Veteran at times has also asserted that his TMJ is secondary to his service-connected psychiatric disability.  The Board must address all theories of entitlement raised by a claimant or reasonably raised by the record. See Robinson v. Peake, 21 F.3d 545, 553 (Fed. Cir. 2008).  In this regard, the December 2016 VA examiner found that the Veteran's TMJ was not due to or the result of his service-connected condition.  The examiner explained that a correlation to major depression could not be made due to the fact that earlier medical records reviewed listed a negative response when asked about depression, and also the VA PHQ-2 depression screening was negative in his medical record, indicating that he did not suffer from depression.  Lastly, on his pre-enlistment medical history form that was completed in 1986, when asked if he suffered from depression, there was a negative response.  

However, the Veteran is clearly service connected for a psychiatric disability.  And the examiner did not provide an opinion regarding whether TMJ has been aggravated by psychiatric disability.   

Thus, in light of the above, the Board finds that an addendum opinion is necessary to address the issues of direct and secondary causation.  

The matters are REMANDED for the following action:

1. Obtain an addendum opinion to address the nature and etiology of any spinal bone spurring.  The need for another examination is left to the discretion of the clinician.  After reviewing the record, the examiner must reconcile the inconsistent findings of the October 2023 VA examination that found no bone spurring of the spine based on x-ray and the May 2014 VA study which indicated that bone spurring was present on the thoracic spine.
 not provide an opinion regarding whether TMJ has been aggravated by psychiatric disability.   

Thus, in light of the above, the Board finds that an addendum opinion is necessary to address the issues of direct and secondary causation.  

The matters are REMANDED for the following action:

1. Obtain an addendum opinion to address the nature and etiology of any spinal bone spurring.  The need for another examination is left to the discretion of the clinician.  After reviewing the record, the examiner must reconcile the inconsistent findings of the October 2023 VA examination that found no bone spurring of the spine based on x-ray and the May 2014 VA study which indicated that bone spurring was present on the thoracic spine.  If the examiner finds that there is no diagnosis of spinal bone spurring, the examiner must adequately explain this finding.  If the examiner finds a diagnosis of spinal bone spurring, the examiner must opine as to the following:

(a.) Is it at least as likely as not that the bone spurring was incurred in, aggravated by, or otherwise attributable to, an event, injury, or incurrence during the active duty, to include the October 1988 motor vehicle accident? 

(b.) If spinal bone spurring is found to not be directly related to service - Is it at least as likely as not caused by service-connected lumbar strain and/or cervical strain; or aggravated (any incremental increase, even transient regardless of permanence), by service-connected lumbar strain and/or cervical strain?

The examiner must offer a detailed rationale for their opinions. The examiner must consider service treatment records, post-service treatment records, and the Veteran's lay statements and hearing testimony.  With respect to secondary service connection, the examiner must consider any causal link between the Veteran's spinal bone spurring and lumbar strain and cervical strain.  The examiner must also provide separate rationales for both secondary causation and aggravation.

2. Obtain an addendum opinion to address the nature and etiology of the Veteran's TMJ.  The need for another examination is left to the discretion of the clinician.  After reviewing the record, the examiner must opine as to the following:

(a.) Is it at least as likely as not that TMJ was incurred in, aggravated by, or otherwise attributable to, an event, injury, or incurrence during the Veteran's active duty, to include any dental procedures and the October 1988 motor vehicle accident?

(b.) If TMJ is found to not be directly related to service - Is it at least as likely as not that TMJ was caused by service-connected adjustment disorder; or aggravated (any incremental increase, even transient regardless of permanence), by service-connected adjustment disorder.

The examiner must offer a detailed rationale for their opinions.  The examiner must consider service treatment records, post-service treatment records, and the Veteran's lay statements and hearing testimony.  With respect to secondary service connection, the examiner must consider any causal link between the Veteran's TMJ and adjustment disorder.  The examiner must also provide separate rationales for both secondary causation and aggravation.

 

 

C. J. McEntee

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J.N. Moats, 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.