Citation Nr: 0003222 Decision Date: 02/09/00 Archive Date: 02/15/00 DOCKET NO. 97-11 697 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michael F. Bradican, Associate Counsel INTRODUCTION The veteran served on active duty from September 1965 to February 1966. Prior to his active service he had two years and three months of service in Naval Reserves. This case arises before the Board of Veterans' Appeals (Board) on appeal from a rating decision of February 1997, from the Roanoke, Virginia, Regional Office (RO) of the Department of Veterans Affairs (VA). This claim first came before the Board in February 1998. It was remanded at that time to secure VA medical records and any additional private treatment records available. All requested development has been completed and the claim is once more properly before the Board. FINDINGS OF FACT 1. The veteran was discharged from the Navy in February 1966 after being found unsuitable for further service due to an emotionally unstable personality. 2. Private medical records show treatment related to anxiety and situational depression beginning in June 1980. 3. VA treatment began in 1993. The current diagnosis is recurrent major depression. 4. No medical evidence or opinion has shown a relationship between the veteran's discharge from service due to a personality disorder and his current psychiatric disorder. CONCLUSION OF LAW The veteran's claim for service connection for an acquired psychiatric disorder is not well grounded and is denied. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION A claimant filing for VA benefits has the duty to submit evidence that must "justify a belief by a fair and impartial individual" that the claim is plausible, and, therefore, well grounded. 38 U.S.C.A. § 5107(a). A claim is not well grounded if the claimant fails to present such evidence. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Evidentiary assertions by the claimant must be accepted as true for the purpose of determining if a claim is well grounded, except where such assertions are inherently incredible or beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19 (1993). For a claim of service connection to be well grounded, there must be competent evidence of current disability, of the incurrence or aggravation of a disease or injury during service, and of a nexus between the inservice injury or disease and the current disability. That is, an injury during service may be verified by competent medical or lay witness statements; however, the presence of a current disability requires a medical diagnosis; and, where an opinion is used to link the current disorder to a cause or symptoms during service, a competent opinion of a medical professional is required. Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131. Regulations also provide that service connection may be established where all the evidence of record, including that pertinent to service, demonstrates that the veteran's current disability was incurred in service. 38 C.F.R. § 3.303(d). A review of the veteran's service medical records shows he was seen in December 1965 because of difficulty adjusting. He described a life-long history of poor interpersonal relationships. He stated that he had few friends because people would get angry towards him for no apparent reason. He reported that he did not like violence or loud talking and that people who drank frightened him. Personnel aboard his ship were allegedly yelling at him for no apparent reason and this made him nervous. He was poorly motivated for continued naval service and felt that if he could not get out he would crack. Mental status examination showed his affect was bland with mild anxiety. His stream of thought was coherent but vague. His content of thought revealed the use of the mental mechanisms of isolation of affect and denial and rationalization. He gave a history of a father who had a violent temper and often argued and fought with his mother. His brother drank and would get violent with his mother. He used these for his reasons for his distaste of violence. He finished high school but allegedly had no friends because he made them angry. The impression given was emotionally unstable personality, passive aggressive type. It was recommended that he be administratively discharged by reason of unsuitability. The examiner commented that he had been duly diagnosed with a character and behavioral disorder which did not require and would not benefit from psychiatric hospitalization. Private medical records, dated in June 1980, show the veteran treated for situational depression related to trouble with his wife and at work. Private records dated between June 1980 and March 1989 show the veteran at various times described as anxious, uptight, and depressed. He was prescribed medication by his general practitioner. VA records first show treatment in June 1993 for mild, agitated depression. In January 1994 he was diagnosed with major depression primarily related to financial stress. VA treatment records, dated in May 1994, show the veteran reporting disputes with his mother and brother regarding their attempts to evangelize him. He stated that as a child his father would take the other children in the neighborhood fishing, but not the veteran or his siblings. He stated that he believed his father was ashamed of him. He complained of emotional abuse by his father. In February 1995 his diagnosis was briefly changed to BI- polar, however, in March 1995 the diagnosis was again reported as recurrent depression. In August 1995 a further diagnosis of Cluster B personality features was added. At that time he described his father as very belittling during childhood. It was also noted at that time that the veteran had been charged with fraud in connection with a business dispute. He gave a history of psychiatric treatment beginning in 1994. He reported that a "fog of confusion" overtook his life about two years prior and that he was currently facing financial hardship. In September 1995 a diagnosis of rule out BI-polar disorder, major depressive episode, and schizoaffective disorder was entered. In December 1995 the diagnosis was again described as recurrent major depressive episodes with Cluster B personality features. The Board notes the veteran's testimony at his personal hearing, conducted in June 1997. The veteran stated that he got along with everyone in High School and that he participated in athletics on the track team. He reported that at the age of 17 he was a school bus driver. He stated that he graduated second in his class during Navy training as a boiler technician and had no problems there or in basic training. He stated that after reporting to his first shipboard assignment other sailors taunted him and he lost interest in his work. He stated that he began to have difficulty dealing with others. He reported that upon his return home his mother saw a 100 percent change in him and urged him to seek private treatment. He stated that he began private treatment shortly after his discharge at a general practitioner named Dr. Shreves, who prescribed medication. After that he stated he was treated by Dr. Duffer until 1980, and then by Dr. Carter. He reported that he believed it was possible that Dr. Carter had records from Dr.'s Duffer and Shreves. He stated that he was currently diagnosed with BI-polar disorder and was being treated by VA with lithium and Trazodone. He claimed that he believed that he was depressed in service and that he now feels like a failure because he has two brothers and an Uncle who continued in military service and retired. The veteran's mother has submitted a statement on his behalf, dated in January 1999. She reported that before active duty the veteran was a happy go lucky young boy and that after discharge she and her husband noticed a big change in him. His attitude was not good. In statements, dated in March and April 1999, the veteran reported that he had been unable to locate any records from Drs. Cooper and Duffer, and that Dr. Carter had sent his records to VA. He stated that it was Dr. Cooper who first treated him after his discharge from service. He stated that he was treated by Dr. Cooper for depression and had been given Valium. He reported that he was treated by Dr. Shreves in the early 1970's and that Dr. Duffer took over that practice. Dr. Carter later joined and the practice was renamed Alta-Vista family practice. Records received by VA from Dr. Carter contain treatment records dated from April 1980 to June 1992. The Board has carefully reviewed the evidence of record to determine if there is a well-grounded claim for service connection for an acquired psychiatric disorder. The first element required to show a well-grounded claim is met because the medical evidence shows that the appellant has been diagnosed with recurrent major depression by VA. The second element of Caluza is also met because the appellant has stated that he experienced problems with nervousness and depression during service. However, the third element of a well- grounded claim is not met because the appellant fails to show the required nexus between his psychiatric disorder and any injury or disease in service. There is no medical evidence establishing a link of the current disorder to the appellant's active military service. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Franko v. Brown, 4 Vet. App. 502, 505 (1993). Medical diagnoses involve questions that are beyond the range of common knowledge and experience. They require the special knowledge and experience of a trained medical professional. Although the appellant has presented statements and testimony regarding his disability and his belief that it was ongoing from discharge, the record does not show that he is a medical professional, with the training and expertise to provide clinical findings regarding any etiological relationship of his current disorder to service. Consequently, his lay statements, while credible with regard to his subjective complaints and history, are not competent evidence for the purpose of showing a nexus between current complaints and service. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The objective evidence of record shows no relationship between the veteran's remote active naval service and his current psychiatric disorder. Treatment records from 1993 to 1996 show no history by the veteran of treatment subsequent to service. Private treatment records show treatment beginning in1980 for anxiety and depression related to marriage and job difficulties, but show no prior history of treatment for mental problems or any relationship to service. The veteran has stated that records of earlier treatment claimed by him are not available. Based upon the foregoing, the Board concludes that the appellant has failed to meet his initial burden of presenting evidence that his claim for service connection for an acquired psychiatric disorder is plausible or otherwise well grounded. Therefore, it must be denied. Where the veteran has not met his initial burden, VA has no duty to assist him in developing facts pertinent to his claim, including no duty to provide him with a medical examination. 38 U.S.C.A. § 5107(a); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992) (where the claim was not well grounded, VA was under no duty to provide the veteran with an examination). However, in the limited circumstances where a claim for benefits is incomplete and the veteran refers to other known and existing evidence which, if submitted, could make his claim well grounded, VA is obliged under 38 U.S.C.A. § 5103(a) to advise the claimant of the evidence needed to complete his application, and this duty must be based on the facts of each case. See Robinette v. Brown, 8 Vet. App. 69, 80 (1995). In this case, the RO substantially complied with this obligation in the statement of the case issued in March 1997. Unlike the situation in Robinette, he has not put VA on notice of the existence of any specific evidence that, if submitted, could make this claim well grounded. Although the RO did not specifically state that it denied the appellant's claim for service connection for an acquired psychiatric disorder on the basis that it was not well grounded, the Board concludes that this error was not prejudicial to him. See Edenfield v. Brown, 8 Vet. App. 384 (1995). Accordingly, the Board denies the appellant's claim for service connection for an acquired psychiatric disorder as not well grounded. ORDER Entitlement to service connection for an acquired psychiatric disorder is denied. KATHLEEN K. GALLAGHER Acting Member, Board of Veterans' Appeals