PSYCHOSIS

BETHANY L. BUCK · 2026 · Case ID: A26038685

MIXED

Summary

The veteran, who served honorably in the Navy from February 1973 to April 1973, appeals the denial of service connection for an acquired psychiatric disorder, traumatic brain injury (TBI), and a cervical spine disability. The Board denied the psychiatric disorder claim due to a lack of current diagnosis in the record, noting that while the veteran reported symptoms and a positive depression screening from a non-VA provider, no objective clinical evidence of a diagnosed psychiatric disorder was present. The Board also denied the TBI and cervical spine claims, finding no current diagnosis for these conditions in the record. While the veteran described an in-service pool diving incident causing head and neck trauma, the Board found no objective medical evidence linking these to a current TBI or cervical spine disability, and noted that post-service treatment records for neck pain resolved. The Board found the veteran competent to describe his experiences but not to diagnose his conditions, giving more weight to the lack of objective medical evidence. The Board denied these claims, finding the evidence against them and not in equipoise. However, the claim for vertigo was remanded because the Board found a pre-decisional duty to assist error in failing to obtain a VA examination. The veteran's non-VA records indicated vertigo symptoms following the in-service incident, and the Board found the McLendon criteria met for remand, requiring a VA examination to determine if vertigo is related to service.

Rationale

No current diagnosis of acquired psychiatric disorder; No objective clinical evidence of psychiatric diagnosis; Non-VA records showed negative screenings for psychiatric disorders

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210216-141201

Full Decision Text

Citation Nr: A26038685
Decision Date: 04/24/26 Archive Date: 04/24/26

DOCKET NO. 210216-141201
DATE: April 24, 2026

ORDER

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

Entitlement to service connection for a traumatic brain injury (TBI) (claimed as head injury) is denied.

Entitlement to service connection for a cervical spine disability (claimed as neck injury) is denied.

REMANDED

Entitlement to service connection for vertigo is remanded.

FINDINGS OF FACT

1. The Veteran has not had a diagnosed acquired psychiatric disability, to include depression, during the appeal period or recent in time to his claim.

2. The Veteran does not have a currently diagnosed TBI disability.

3. The Veteran has not had a diagnosis for a cervical spine disability at any time during or approximate to the pendency of the claim, and his neck pain does not result in functional impairment.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.125.

2. The criteria for entitlement to service connection for a TBI (claimed as head injury) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for entitlement to service connection for a cervical spine disability (claimed as neck injury) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably on active duty from February 1973 to April 1973.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA).

By way of history, this matter was previously before the Board in August 2017, at which time it was remanded to the Agency of Original Jurisdiction (AOJ) for further evidentiary development. Following such development, the Board denied the Veteran's claims in September 2018.

The Veteran subsequently appealed the denials to the United States Court of Veterans Claims (Court). The Court issued a memorandum decision in March 2020, which found that the Board erred when it did not ensure that VA complied with its duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the Veteran's claims. As a result, the Veteran's claims were returned to the Board.

In November 2020, the Board again remanded the claims to the AOJ for further evidentiary development consistent with the Court's March 2020 memorandum decision. Following the remand, the RO issued a Supplemental Statement of the Case (SSOC) in January 2021. In a February 16, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran appealed the January 2021 SSOC and opted-in to the Appeals Modernization Act (AMA) review system. He elected the Board's Hearing docket. A Board hearing was held on July 30, 2024, and a transcript of the hearing is associated with the claims file.

Therefore, the Board may only consider the evidence of record at the time of the January 2021 SSOC, as well as any evidence submitted by the Veteran or his representative at the July 2024 Board hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the July 2020 SSOC and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted and the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for
July 2020 SSOC and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted and the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claim of entitlement to service connection for vertigo, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

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. Generally, service connection requires three elements: (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).

Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or is aggravated beyond its natural progression, by service-connected disability. 38 C.F.R. § 3.310.

In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

1. Entitlement to service connection for an acquired psychiatric disorder is denied.

The Veteran contends that he has an acquired psychiatric disability due to service, stating that he experienced traumatic events which caused him to fear for his life when in training in the Navy's pool. Specifically, the Veteran asserts that he was forced to dive into a pool during training on active service, and not being an experienced swimmer, he hit his head and neck upon impact with the water that he began to drown. He asserts that after this diving incident, he feared for his life when he was being forced to participate in training in the pool. See e.g., July 2010 VA 21-4138 Statement in Support of Claim; June 2013 Correspondence; February 2021 Correspondence.

The claim must be denied due to no current disability at any time during the pendency of the claim or recent to the filing of the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020), aff'd sub nom. Martinez-Bodon v. McDonough, 28 F.4th 1241 (Fed. Cir. 2022) (holding that a mental health disorder requires a valid DSM-5 diagnosis).

The Veteran asserts that his service treatment records (STRs), lay statements, and hearing testimony corroborate that the diving pool incident did occur, which should serve as a sufficient stressor for a diagnosis of posttraumatic stress disorder (PTSD). See July 2024 Board Hearing transcript.

Further, the Veteran contends that he has severe depression as a result of this diving pool incident. See May 2010 informal claim.

That record reflects that the Veteran sought treatment from a non-VA primary care provider. The Veteran submitted records from the non-VA primary care provider in October 2020. These records reflect one instance of a positive screening for depressive symptoms. See August 17, 2018, non-VA primary care note. Additionally, the Veteran endorsed feelings of anxiety when someone knocked on his door; but indicated that he does not see a mental health provider due to the cost. See November 26, 2018, non-VA primary care note. However, the records also contain denials from the Veteran regarding mental health symptoms, such as anxiety and nervousness, and negative screenings for depression, as well as findings of normal mood
claim.

The Veteran has not identified any VA treatment, and he has not provided or authorized VA to obtain any more recent private or non-VA treatment records.

Based upon a review of the evidentiary record before the Board, there are no private or VA treatment records that reflect a diagnosis of depression or another acquired psychiatric disorder. While the Board acknowledges that the non-VA treatment records submitted by the Veteran contain mentions of psychiatric symptoms, as well as a positive screening for depression, the records also reflect negative screenings for psychiatric or behavioral disorders. The medical records reflect no psychiatric diagnosis of any kind.

VA's duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006).

In this case, there is no objective clinical evidence during the appeal that he has been diagnosed with a psychiatric disability. As there is no competent evidence of record indicating the Veteran has a diagnosed psychiatric disorder, depression or otherwise, a medical examination or opinion is not necessary to decide the claim. Thus, this duty to assist has not been triggered.

In summary, the evidence is not in at least relative equipoise as to a diagnosis for an acquired psychiatric disorder to show a current disability, and there is no reasonable doubt to be resolved in the Veteran's favor. The appeal must be denied.

2. Entitlement to service connection for a traumatic brain injury (TBI) (claimed as head injury) is denied.

3. Entitlement to service connection for a cervical spine disability (claimed as neck injury) is denied.

The Veteran contends that he injured his head and neck during his active service. Specifically, the Veteran asserts that he was forced to dive into a pool during training on active service, and not being an experienced swimmer, he hit his head and neck upon impact with the water and that he began to drown. He reports that he somewhat lost consciousness, and after this incident, has experienced TBI symptoms, as well as difficulties with his cervical spine. See July 2010 VA 21-4138 Statement in Support of Claim.

As to the first element required for service connection, the Veteran must show a current disability. The Veteran's records do not have any documentation of a medical diagnosis of TBI during the appeal period. The record reflects non-VA treatment records which contain mention of a physical assault that occurred on August 4, 2016, where the Veteran was knocked unconscious following a blow to the head and mouth. The Veteran underwent a brain CT scan, which was normal. He was assessed with a closed head injury and contusion to the scalp. See August 14, 2016, non-VA treatment records.

The medical evidence of record also does not contain diagnosis of a chronic cervical spine disability. The Board acknowledges that upon review, there are non-VA treatment records from August and September 2016, where the Veteran sought treatment for back and neck pain, secondary to the physical assault that occurred on August 4, 2016 (many years after the Veteran had separated from service). The Veteran reported pain in his neck and back and was assessed with an acute neck sprain. Additionally, in 2017, the Veteran was involved in a motor vehicle accident when again resulted in back, neck, and shoulder pain. He was assessed with a neck sprain. See November 30, 2017,
6, non-VA treatment records.

Further, there are no VA medical records for the Board to review. Upon review of the Veteran's service treatment records (STRs), there is no documentation in the Veteran's STRs regarding symptoms and/or concerns regarding a TBI, concussion, and/or neck pain/injury.

The Veteran testified during the July 2024 Board Hearing regarding the in-service incident described above, the dive into the pool, which resulted in his claimed injuries. However, the Veteran did not provide any testimony as to when or how he was diagnosed with the claimed TBI or cervical spine disability.

In considering the evidence, the Board finds that service connection for the Veteran's TBI and cervical spine disability is not warranted.

While the Veteran is competent to describe his experiences during his active service, to include the diving pool incident, and certainly credible to describe the neck pain he experiences, or the symptoms of dizziness and confusion he endorses that he states are a result of a TBI, the Board notes that the most probative evidence of record does not support a finding of a cervical spine disability or a TBI disability. Further, while the Veteran is competent to identify the presence of observable symptomatology, he is not competent to provide a diagnosis, such as that of a TBI or cervical spine strain, as that requires medical expertise and is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Hence, the Board gives more probative weight to the competent medical evidence.

The Board recognizes that pain resulting in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). However, in this case, there is no functional impairment of the neck described at any point in the record. The Veteran has not endorsed difficulty due to his neck pain. Accordingly, the Board concludes that the Veteran does not have a cervical spine disability at any time during the pendency of the claim or recent to the filing of the claim for neck pain. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).

The Veteran has not been afforded a VA examination with respect to his claim for service connection for TBI and cervical spine disability, but no examination is required because the lay and medical evidence does not show that the claimed disabilities, or symptoms thereof, may be associated with the Veteran's active service. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Under McLendon, VA is obligated to provide an examination only when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).

The standards of McLendon are not met in this case. Here, the Veteran has not described any persistent or recurrent symptoms that he believes could substantiate a disability like TBI or a neck problem
of a current disability (or persistent or recurrent symptoms of a disability), (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).

Accordingly, the Board finds that the persuasive evidence is against the claims for service connection for TBI and a cervical spine disability. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Entitlement to service connection for vertigo is remanded.

The Veteran contends that he injured his head and neck during his active service, which resulted in his current vertigo symptoms. Specifically, the Veteran asserts that he was forced to dive into a pool during training on active service, and not being an experienced swimmer, he hit his head and neck upon impact with the water and that he began to drown. He reports that he somewhat lost consciousness, and after this incident, water got into his ears which caused dizziness, ringing, and severe pain. See July 2010 VA 21-4138 Statement in Support of Claim.

As this appeal is governed by the AMA, remand is only permitted to correct an error in the duty to assist that occurred prior to the rating decision on appeal. 38 C.F.R. § 20.802. Accordingly, the Board finds the AOJ committed a pre-decisional duty to assist error in not obtaining a VA examination and opinion for the issue of entitlement to service connection for vertigo. 38 C.F.R. § 20.802.

Remand is required to obtain a VA examination. In McLendon v. Nicholson, 20 Vet. App. 79 (2006), the Court indicated that there was a four-part test to determine whether an examination was necessary under 38 C.F.R. § 3.159(c)(4). Id. at 81. Under this test, VA will provide a medical examination or obtain a medical opinion where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence to make a decision on the claim. Id.; see also 38 C.F.R. § 3.159(c)(4).

In non-VA treatment records throughout the period on appeal, the Veteran has complained of symptoms such as dizziness or feelings of imbalance, and experiencing vertigo repeatedly. Treatment records from April 2002, the Veteran sought treatment with complaints of lightheadedness and vertigo for over a week. In non-VA treatment records from October 2008, the Veteran again complained of feeling off balance and experiencing a "spinning" feeling; he described the feeling as vertigo. The provider indicated that the Veteran should obtain a MRI. A follow up treatment note reflects that the tests were inconclusive for vestibular findings. In November 2009 non-VA treatment records, the Veteran sought treatment for "increased vertigo symptoms" over a week's time.

The Board finds that in this case, the McLendon criteria have been met. Here, as noted above, the Veteran's non-VA treatment records confirm treatment for vertigo. Second, the Veteran has provided competent and credible lay statements including testimony that he began experiencing symptoms of vertigo following the diving pool incident during his active service. He further contends that he has experienced vertigo and the associated symptoms since his active-duty service. However, the Board lacks sufficient information to decide the claim.

As a result, the Board cannot make a fully informed decision on the issue of entitlement to service connection for vertigo because no VA examination has been performed and no VA examiner has opined whether the Veteran's vertigo was the result of service. Therefore, a VA examination is necessary.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA examination for vertigo. The examiner must review the
igo. Second, the Veteran has provided competent and credible lay statements including testimony that he began experiencing symptoms of vertigo following the diving pool incident during his active service. He further contends that he has experienced vertigo and the associated symptoms since his active-duty service. However, the Board lacks sufficient information to decide the claim.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA examination for vertigo. The examiner must review the claims file.

The examiner must opine whether it is at least as likely as not that the Veteran's vertigo is related to an in-service injury, event, or disease, to include the consideration of the Veteran's lay statements regarding his experience with the diving pool.

In providing the requested opinion, consider the Veteran's description of the in-service injury and symptoms as well as post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of the current disability, this should be noted. Stated another way, do the Veteran's reports about the symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible?

Note that the lack of documented treatment in service, or a long period after, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions must be considered and weighed in making the determination.

The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the likelihood is at least approximately balanced or nearly equal, if not higher.

Bethany L. Buck

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board R. M. Lowman, 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.

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