Citation Nr: 1736593	
Decision Date: 08/31/17    Archive Date: 09/06/17

DOCKET NO.  13-19 596	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Portland, Oregon


THE ISSUE

Entitlement to service connection for residuals of a head injury, to include traumatic brain injury (TBI) and an acquired psychiatric disorder.


REPRESENTATION

Appellant represented by:	Oregon Department of Veterans' Affairs


ATTORNEY FOR THE BOARD

T.Y. Hawkins, Counsel






INTRODUCTION

The Veteran had honorable active duty service with the Marine Corps from June 3, 1991 to June 28, 1991.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon.

In January 2017, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for additional evidentiary development.  As there has been substantial compliance with the Board's remand directives, the Board finds there is sufficient evidence to adjudicate the claim.  See Stegall v. West, 11 Vet. App. 268, 271 (1998). 


FINDINGS OF FACT

1.  The Veteran's service treatment records show that he sustained a mild head injury during service.

2.  The probative and competent evidence fails to demonstrate that the Veteran sustained a TBI in service or that his current mental health disorder is the result of a head injury during service.

3.  The probative and competent evidence fails to demonstrate that the Veteran's current schizophrenia, paranoid type, developed during service, or is the result of an injury, event or incident of service.


CONCLUSION OF LAW

The criteria for service connection for residuals of a head injury, to include TBI, or 

for an acquired psychiatric disorder, are not met.  38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2016). 


REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran asserts that he sustained a TBI during service as a result of being kicked in the head by a fellow soldier.  In addition, he claims that he has posttraumatic stress disorder (PTSD) as a result of being punched in the stomach by his drill sergeant.

To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability.  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

The question for the Board is whether the Veteran has residuals of a TBI that occurred during service, or whether his current diagnosis of schizophrenia, paranoid type, or any other diagnosed acquired psychiatric disorder manifested during, or is the result of some injury, event or incident of service.

Based on review of the complete evidence of record, the Board finds that the competent, credible, and probative evidence fails to support the Veteran's claim of entitlement to service connection for residuals of a head injury, to include TBI and an acquired psychiatric disorder.

First, the Board finds that while the Veteran sustained a head injury in service, it did not result in a TBI.  

Review of his service treatment records shows that on June 11, 1991, he was seen in the emergency room of the San Diego, California, Naval Hospital with reports having been struck on the right side of the head by a fellow service member resulting in a loss of consciousness (LOC).  It was noted that he was fully-oriented.  After evaluation, including a negative head CT, he was released to full duty, with a notation that his condition had "improved."  

This evidence strongly suggests that he did not sustain a TBI in service despite being injured and losing consciousness.  

A mental health evaluation , on June 13, suggests that he had a personality disorder and was incompatible with military service.  On mental status examination, he was fully-oriented and his speech was clear and coherent.  He was diagnosed with a personality disorder, not otherwise specified (NOS), with immature and passive aggressive traits.  Additional service treatment records asserted that many of his complaints during his brief period of service were not found to be truthful.  The clinician recommended that he be removed from service for nonadaptability/ unsuitable to military service.  

Post-service treatment reports from the Social Security Administration (SSA) show that the Veteran did not begin receiving mental health treatment until October 2001, at Cascadia, a private facility.  In December of that year, he was diagnosed with undifferentiated schizophrenia, obsessive-compulsive disorder (OCD), alcohol dependence and polysubstance abuse.  These records do not suggest a service origin of any acquired psychiatric disorder.  

In October 2009, a private psychiatrist diagnosed him with schizophrenia, NOS; anxiety disorder, NOS; alcohol dependence in partial remission and cannabis abuse.  This finding is consistent with the then-evidence of record, but it does not suggest that a psychiatric disability is related to his military service.  

In December 2010, the Veteran was afforded a VA TBI examination.  In reviewing the service treatment records, the examiner noted that the June 1991 emergency room treatment report showed no evidence of any head trauma (although there was tenderness in the right temporal area), and a neurological examination was without deficits.  He also noted the service reports showed the Veteran's reports of somatic complaints and inability to adapt to military life.  During the examination, he claimed to have PTSD as a result of childhood physical and sexual abuse and reported that he had been variably diagnosed with schizophrenia versus depression, anxiety and OCD.  The examiner opined that TBI was not diagnosed.  He said that the history, as provided by the Veteran, and review of the service treatment records documenting the medical examination immediately following his injury did not suggest a TBI.  He further opined that his neurocognitive complaints were not due to TBI, and were more consistent with a mental health condition.

This evidence is clearly against the claim as it shows that he does not have a current TBI and that a psychiatric condition is not service-related.  

During a psychodiagnostic examination in February 2011, a private clinician noted that the Veteran reported auditory hallucinations "in a believable way," and appeared delusional during the interview.  The diagnosis was schizophrenia, paranoid type, and OCD, rule out PTSD.  He was subsequently granted SSA disability insurance benefits, effective September 2004, for a primary diagnosis of personality disorders, and a secondary diagnosis of substance addiction/dependence disorders (drug).

During an April 2011 intake evaluation at Cascadia, the Veteran reported that he sometimes got headaches.  He said he had had two concussions, for which he was seen in the emergency room, but then said that he had had at least eight, and that he belonged to a fight club.  This evidence suggests that the Veteran is not a good historian and also indicates that there may be post-service explanations for his current headache complaints.  

In January 2017, the Veteran's claims file was reviewed for a neurological opinion as to the nature and etiology of any current residuals of his in-service head injury, to include TBI and any current mental health disability.  In opining that a TBI diagnosis was not supported by the evidence of record, the examiner noted that the Veteran's service treatment records showed that he had a relatively minor head injury without LOC or amnesia.  He pointed out that he was alert and oriented on initial examination (indicating no altered level of awareness or confusion) and his head CT was negative.  He added that the service treatment records did not show a diagnosis of a concussion or TBI in service and the Veteran had been diagnosed with paranoid schizophrenia and OCD, which he said were the cause of the cognitive/behavioral changes reported by the Veteran and his family members, and documented by mental health professionals.   He further noted that the Veteran had a variety of somatic complaints, which he said were related to his mental health conditions, one of which was persistent headaches.   He said that, given the mild nature of his in-service head injury without TBI, persistent headaches due to this closed head injury were less than likely, and that his complaints of headaches were not consistent with a primary headache disorder, but and were more likely than not a manifestation of somatization disorder.  Finally, he opined that a mental health examination would be needed to determine if the Veteran actually had PTSD as a result of his head injury or purportedly being punched by his drill sergeant.

In April 2017, the Veteran's claims file was reviewed for an opinion as to whether any current psychiatric disability, to include PTSD, was incurred in, aggravated by, or was otherwise due to his period of active service.  The clinician opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness.  He explained that his in-service health assessment on June 13, 1991 showed no evidence of a thought disorder and his thinking was described as coherent; he was noted to be disruptive to the unit and was having somatic complaints; he was recommended for discharge due to not adjusting to the military; and he was diagnosed with an occupational problem and a personality disorder, NOS.  He further noted that the Veteran's mental health records showed a history of having been diagnosed with Schizophrenia in 2001, and that the examiner who performed the January 2017 examination noted the Veteran had a mild head injury and was not diagnosed with a TBI.  He thus concluded that, based on the Veteran's service treatment records and post-service mental health records, there was no nexus between his current mental health issues and his brief period of military service.

In sum, these examination results are evidence showing that the Veteran does not have PTSD, a TBI, or an acquired psychiatric disability that is related to service.  

Accordingly, the Board finds that the criteria for service connection for the Veteran's claimed TBI or acquired psychiatric disorder have not been met.


ORDER

Entitlement to service connection for residuals of a head injury, to include traumatic brain injury (TBI) and an acquired psychiatric disorder is denied.




____________________________________________
M. TENNER 
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs

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