Citation Nr: 0011178 Decision Date: 04/27/00 Archive Date: 05/04/00 DOCKET NO. 95-26 076 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania THE ISSUE Entitlement to secondary service connection for diabetes mellitus. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran served on active duty from May 1966 to January 1970. This matter came to the Board of Veterans' Appeals (Board) from a November 1993 RO decision which granted service connection for post-traumatic stress disorder (PTSD) and rated the condition as 10 percent disabling. The RO increased the PTSD rating to 50 percent in August 1994, and the veteran continued the appeal for a higher rating. He also appealed a May 1995 RO decision that denied secondary service connection for diabetes mellitus (claimed to be secondary to service-connected PTSD). The Board denied the claims for an increased rating for PTSD and secondary service connection for diabetes mellitus in September 1998. The veteran then appealed to the United States Court of Appeals for Veterans Claims (Court). In a May 1999 joint motion to the Court, the parties (the veteran and the VA Secretary) requested that the September 1998 Board decision be vacated and remanded as to the issue of secondary service connection for diabetes mellitus In a May 1999 order, the Court granted the joint motion. [The appeal as to the issue of an increased rating for PTSD was dismissed by the 1999 joint motion and Court order.] The case was subsequently returned to the Board for further action on the claim for secondary service connectin for diabetes mellitus. In October 1999, the Board requested a medical expert opinion. That opinion was obtained in December 1999; a copy was provided to the veteran and his representative, and they were given an opportunity to submit additional evidence and argument. In February and March 2000, they submitted additional written argument and medical evidence, and they waived consideration of the additional evidence by the RO. FINDING OF FACT The veteran's diabetes mellitus began many years after service, and diabetes mellitus was not caused or permanently worsened by service-connected PTSD. CONCLUSION OF LAW The veteran's diabetes mellitus is not proximately due to or the result of service-connected PTSD. 38 C.F.R. § 3.310(a) (1999). REASONS AND BASES FOR FINDING AND CONCLUSION I. Background The veteran served on active duty in the Air Force from May 1966 to January 1970, including service in Vietnam. Entries on the veteran's service enlistment examination (some initial entries were later partially scratched out) indicate that when first examined for enlistment in March 1966, he was found to be unfit for service on the basis that he was overweight (200 pounds); he was advised to lose 9 pounds in order to meet the acceptable weight standard of 191 pounds; and in May 1966, he weighed 191 pounds and was medically accepted for service. The service medical records show no psychiatric disorder or diabetes mellitus, and the January 1970 examination for separation from service noted normal psychiatric and endocrine systems. He weighed 196 pounds. Urinalysis was negative for blood sugar. In a statement received in January 1993, Michael B. Mulcahy, M.S.W., a social worker from Detore and Associates, Achievement and Guidance Centers of America, reported that he began treating the veteran for significant depression in January 1992. It was reported that the veteran's depression had worsened significantly, and that there was a significant increase in self-destructive behavior including a profound increase in body weight. Mr. Mulcahey said that the weight increase had "worsened his blood sugar and diabetic problems which in turn provoke his mood to be more volatile." The social worker diagnosed PTSD on Axis I; on Axis III it was noted he had diabetes with variable control. On a July 1993 VA examination, it was noted the veteran worked as a clinical coordinator at a Vet Center. The diagnosis was PTSD. In November 1993, the RO granted service connection for PTSD and rated the condition as 10 percent disabling. The veteran testified at a hearing at the RO in May 1994 concerning his PTSD claim. At the hearing, his representative stated that the veteran had been informed that stress was becoming a health problem and he was developing a diabetes condition. Later that month, the veteran filed his claim for service connection for diabetes mellitus secondary to PTSD. In a May 1994 letter, Julia T. Mathos, D.O., reported the veteran had been diagnosed with diabetes in November 1991, and since that time had required increased doses of oral hypoglycemic agents to control his sugar, which had been difficult to control. She added there had been many articles written explaining that physical and emotional stress had adverse effects on diabetes, and summarized that stress could adversely affect the veteran's diabetes. Received with her statement were very short summaries from articles from 2 medical journals; one to the effect that stress was a potential contributor to chronic hyperglycemia in diabetes, and one that said lab results showed a significant increase in blood glucose, cardiovascular, and subjective stress ratings on high stress days, and that stress had a hyperglycemic effect. Also submitted was a statement, attributed to N. Feinglos, M.D., from Duke University, that the connection between stress and diabetes mellitus is not new and stress inhibits insulin secretion in diabetes mellitus, type II. On a June 1994 VA psychiatric examination, the veteran reported that he was more preoccupied with incidents in Vietnam and more dysfunctional. There were no findings or mention of diabetes mellitus. The diagnosis was PTSD, very severe. In a June 1994 letter, Mr. Mulcahy (social worker) reported the veteran's depression and anxiety resulted in difficulties with diabetic control, headaches, and weight management. The diagnosis on Axis I was PTSD; Axis III diagnoses included diabetes and obesity. In August 1994, the RO increased the rating for PTSD to 50 percent. On a September 1994 VA medical examination, the veteran reported that diabetes mellitus was diagnosed in October 1991. He reported that he weighed 180 pounds when he graduated from high school and entered the service. He stated that when he separated from service he weighed between 180 and 190 pounds. He reported he started to gain weight steadily since 1970 and by 1983 he weighed over 300 pounds. The diagnoses were marked obesity, PTSD, and type II diabetes in poor control. The examiner stated that PTSD could aggravate symptoms of diabetes mellitus which seemed to be out of control. The veteran testified at an RO hearing in October 1995. He stated that for many years, even as far back as service, he had avoided seeking medical attention for symptoms such as constant thirst because of his PTSD. He said stress triggered diabetic conditions and that he had tingling of his extremities since he returned from Vietnam. In a November 1995 letter, Dr. Mathos listed medications the veteran was taking for diabetes. (No psychotropic medications were listed here or elsewhere in the record.) In October 1996, clinical records were received from Mr. Mulcahy (social worker) concerning treatment beginning in January 1992. The treatment records show approximate monthly (or less) visits through November 1994 and note the veteran was on no medications for PTSD. Mr. Mulcahy mentioned symptoms due to PTSD, including depression and anxiety. In November 1996, a VA doctor, D. S. Kelley, M.D., reviewed the veteran's claims folder. He said that with regard to diabetes mellitus, well-established risk factors were parental history, gestational diabetes, glucose intolerance, obesity (especially when of long-standing duration), and a sedentary life style. He said known aggravating factors were certain medications (steroids and diuretics) and stress - which is generally considered to have acute (i.e., immediate, short-lived) effects to counter the action of insulin and thus potentiate hyperglycemia. In the veteran's case, obesity stood out as the key risk factor. Dr. Kelley said he could not refute that the psychological effects of PTSD contributed to obesity, and perhaps a sedentary life style, and thereby potentiated the risk of developing non-insulin dependent diabetes mellitus, but said a direct causal relationship between PTSD and diabetes mellitus was hard to support, unless one was willing to believe that in the absence of PTSD, the veteran would have remained non-obese. On a January 1997 VA psychiatric examination, the veteran reported he was team chief at a Vet Center. He claimed trauma-based nightmares 3-4 times a week. He reported that he had decreased sleep for the past 3 years to about 4 hours per night. He reported anger/irritability, dissociation, depression and anxiety among the symptoms associated with a diagnosis of PTSD. He presented as an anxious individual. His mood varied between crying and anger. The diagnosis on Axis I was PTSD; the Axis III diagnosis was diabetes. In January 1997 correspondence, John F. Stremple, M.D., reported that the veteran stated that he had had increased blood glucose which had been out of control even with maximum diabetic therapy and wondered if this was related to PTSD. Dr. Stremple reported that elevated blood sugar was related to trauma and response to stress. The doctor included a medical protocol and a medical journal, which showed that hyperglycemia occurred as a result of trauma (physical, not psychic). The doctor added that it was possible that PTSD could cause an exacerbation of blood sugar levels which could require more difficult diabetic therapy. He stated he was aware of no specific clinical data which showed exacerbation of diabetes with PTSD. In a March 1997 statement, Dr. Kelley said that he had been requested by the veteran and his representative to review some literature concerning the adverse health effects of PTSD. In Dr. Kelley's opinion, the articles point out that PTSD had an impact upon physical health among veterans and that the researchers who wrote the articles postulated that abnormal or excessive sympathetic reactivity lay the stage for endocrine disease. Dr. Kelley noted that one report by Dr. Hamner who was affiliated with a VA psychiatric service made the point that PTSD could lead to poor diet habits, lack of exercises and other maladaptive health habits which, in turn, set the stage for chronic illness. Additional articles supplied by the veteran continued in this general area. Dr. Kelley concluded that chronic stress did create a fertile soil from which type II diabetes could germinate. He stated that he was not the proper medical authority to make a judgment as to the degree of chronic stress in the case of the veteran, and this should be the judgment of a clinical psychologist or psychiatrist. He added that it seemed rational to postulate that if the veteran did experience substantial on-going chronic stress from PTSD then this may have been a contributor to the emergence of type II diabetes mellitus. He stated that on the basis of a chart review it was difficult to conclude that PTSD caused diabetes mellitus, nor was it possible to discount such a linkage. He stated that attached medical literature did substantiate that veterans who had PTSD had an increased prevalence of adverse chronic medical conditions and it was relevant to look at the linkage between PTSD and diabetes mellitus in this context, in the veteran's case. Copies of the medical reports and articles are included in the claims file (they were received with the record in January 1997). The articles to a large extent were addressed in the March 1997 VA doctor's statement. In August 1997, a VA doctor, Thomas Horvath, M.D., reported that the veteran had discussed his medical condition (diabetes) and his PTSD. He reviewed a chapter, from a medical treatise, titled "The relationship between Trauma, Post-traumatic stress Disorder and Physical Health" by the Executive Director of the National Center for PTSD, Matthew J. Friedman, M.D. This article, supplied by the veteran, concerned the effects of PTSD on general health. Dr. Horvath added that it seemed that the veteran's diabetes or the exacerbation and control of his diabetes were related to his PTSD. In a March 1998 memorandum, Dr. Matthew Friedman reported that he had reviewed the veteran's claims folder. He stated he had also reviewed the opinions of Drs. Kelly, Stremple and Horvath as well as copies of medical articles submitted by the veteran (one of which Dr. Friedman co-authored). He said that there was literature suggesting an exposure to a variety of (non-traumatic) stressors was associated with exacerbation of a number of medical illnesses, including diabetes. The article from Dr. Stremple was an example of acute metabolic change, hyperglycemia, being due to trauma of being wounded in combat. Dr. Friedman indicated that it was an attractive and reasonable hypothesis that PTSD is associated with a number of abnormalities in major neurobiological systems that may constitute a risk factor for several medical illnesses, but such hypothesis had not been conclusively demonstrated, and that the few studies on the matter did not establish any etiological relationship between PTSD and any medical illness. Dr. Friedman added that he looked forward to a day when published literature will confirm a hypothesis that PTSD was a risk factor for medical illnesses. Even if such evidence did emerge, it was impossible to predict whether such a relationship will be found to be etiological and whether diabetes will be one of the medical illnesses exacerbated by PTSD. Dr. Friedman summarized that the available scientific evidence did not support a claim that PTSD could exacerbate diabetes mellitus. In April 1998, the VA Associate Chief Consultant for Psychiatry, Dr. Lehmann, reported to the director of compensation and pension services that the March 1998 opinion from Dr. Friedman, the Executive Director of the VA's National Center for PTSD, concluded that there was not enough scientific evidence to support an etiological relationship between PTSD and diabetes. It was added that there was a significant body of clinical literature suggesting mental disorders were a complicating factor in metabolic balance and in behaviors necessary for maintaining good diabetic control. With specific regard to the veteran's case, there was evidence that emotional problems exacerbated the ability to maintain diabetic control. He added that it was the cumulative opinion of a number of physicians who have treated the veteran or reviewed his case that PTSD was a "complicating factor" in his diabetes. In October 1999, the Board requested a medical expert opinion from the VA's Veterans Health Administration as to the issue of service connection for diabetes claimed as secondary to PTSD. In response, a December 1999 memorandum was received from Charles A. Buerk, M.D., the Chief of Staff of the VA Central Texas Veterans Health Care System. He stated that the veteran's claims file was reviewed by Chien L. Tsai, M.D., the Chief of Psychiatry Service at a VA facility. The following opinion was rendered: a. The diabetes mellitus was not medically caused by post-traumatic stress syndrome (PTSD). b. There is no scientific evidence that post-traumatic stress syndrome (PTSD) aggravated the condition of diabetes mellitus. We treat PTSD patients with diabetes mellitus, yet their post- traumatic stress syndrome (PTSD) does NOT aggravate their diabetic condition. In contrast, we see diabetic patients without post-traumatic stress syndrome whose condition deteriorates. Currently there is no scientific evidence to link the aggravation of the diabetic condition to post-traumatic stress syndrome (PTSD). In a January 2000 statement to the veteran's representative, a psychologist from the Brooklyn VAMC, Dr. Rachel Yehuda, indicated that she disagreed with the above-cited opinion of the VA Psychiatry Chief. She opined that, "Perhaps the diabetes mellitus was not medically caused by PTSD, but it sure could be affected by PTSD. She added, "PTSD can affect and aggravate both medical and psychiatric conditions. In fact there is recent evidence that if you treate PTSD with cognitive behavioral therapy in the context of a medical condition (liver disease, myocardial infarction), you can actually improve the medical condition through the PTSD treatment. This indicates that PTSD directly mediates the severity of medical illness. It should come as no surprise to anyone since in general stress is known to directly precipitate and exacerbate medical conditions. There does not need to be scientific evidence that PTSD specifically aggravates the condition of diabet[e]s mellit[u]s specifically in order to justify this claim, but rather, there needs to be evidence that PTSD does not aggravate diabet[e]s mellit[u]s in order to deny it. There is no evidence for this latter possibility because no one specifically examined this issue." She added, "one can certainly imagine" that PTSD could have profound deleterious consequences for insulin metabolism because PTSD was associated with low cortisol levels and enhanced glucocorticoid receptor sensitivity. She said understanding of the consequences of PTSD was in its infancy, but there was no doubt that PTSD had "extremely detrimental consequences for physical states" and one "would in particular expect that illnesses that are already present would be most affected by PTSD." In a January 2000 statement to the veteran's representative, Henry R. Mandoff, M.D., reported that he consulted with colleagues in internal medicine, including an endocrinologist, who both felt that stress would lead to an increase in the release of adrenal cortical steroid hormone, that would lead to hyperglycemia. The doctor said that, with continued stress, this would aggravate an underlying latent diabetes, and probably lead to a full blown case. The endocrinologist reportedly cited instances of cases in burn units and cases with massive infections that became hypoglycemic and later manifested symptoms consistent with the diagnosis. Dr. Mandoff said he disagreed with the opinion of the VA Chief of Psychiatry. In a January 2000 statement by the veteran and in a February 2000 statement by his representative, it was emphasized that the claim for secondary service connection for diabetes was based on PTSD exacerbating the diabetes, and that he was not asserting that PTSD medically caused diabetes mellitus. Attention was directed to supporting medical statements on file. In March 2000, the veteran submitted copies of more medical articles, similar to ones earlier submitted. These generally note that stress can adversely affect diabetes, and that diabetic symptoms may have an adverse affect on marital adjustment. II. Analysis The veteran's claim for secondary service connection for diabetes mellitus is well-grounded, meaning plausible; the VA has fulfilled its duty to assist him in developing the facts pertinent to his claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service incurrence for diabetes mellitus will be presumed if manifest to a compensable degree within one year of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Diabetes was not shown during service, within the first year after service (as required for presumptive service connection), or for many years later. It is neither claimed nor shown that diabetes should be service connected on a direct or presumptive basis. Rather, the veteran claims secondary service connection for diabetes mellitus, asserting that it is related to his service-connected PTSD. Secondary service connection will be granted when a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may be established for a condition which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The evidence shows the veteran was first diagnosed with diabetes in 1991, prior to the first evidence of psychiatric treatment in 1992. The evidence indicates that the diabetes came first, and thus was not caused by later PTSD. One of the veteran's prior assertions was that his service-connected PTSD made him become obese (presumably due to overeating and inactivity) which, in turn, led to diabetes. Yet the evidence is to the contrary on this point. His weight problem predates service (he was initially rejected for enlistment because he was overweight), and he reports he gained over 100 pounds in 13 years immediately after service, which was years before PTSD appeared. In recent correspondence, the veteran and his representative emphasized that they are not claiming that service-connected PTSD medically caused diabetes; rather, they are claiming that service-connected PTSD is aggravating diabetes. That is, the veteran claims secondary service connection under the theory of aggravation as set forth in Allen, supra. In Allen, the Court held that secondary service connection under 38 C.F.R. § 3.310 is permitted not only when an established service-connected disorder causes another disease or injury, but also when a service-connected disorder results in aggravation (an increase in severity) of a non-service- connected condition. The Court noted, however, that in the aggravation situation, compensation may only be awarded for the degree of the non-service-connected disability which is over and above the degree of disability which existed prior to the aggravation. Allen at 448. The Court cited, as analogous support, 38 C.F.R. § 3.322, a regulation which concerns evaluations of preservice disabilities which are service connected by reason of being aggravated by service; this regulation notes that the evaluation for such a condition is generally determined by substracting the preservice level of disability (as determined under the rating schedule) from the current level of disability (as determined under the rating schedule). In view of Allen, it appears that for secondary service connection to be granted by way of aggravation, there must be an identifiable and measurable increment of additional chronic disability which was caused by a service-connected disorder. Following the Court remand in the instant case, the Board obtained a VA medical expert opinion on the issue of secondary service connection. The VA doctor reviewed the veteran's records and unequivocally opined that the veteran's service-connected PTSD neither caused nor aggravated his diabetes mellitus. This opinion soundly rejects both the causation theory and the Allen aggravation theory of secondary service connection. See also McQueen v. West, 13 Vet.App 237 (1999). The Board gives much weight to this medical opinion as it was based on actual review of the veteran's records, including a number of earlier opinions for and against the claim. Some of the earlier medical statements on file are also clearly against secondary service connection, by either causation or aggravation. The veteran has submitted a number of medical statements in support of his claim for secondary service connection for diabetes. Some of these statements offer support for PTSD causing diabetes, but most do not; and, as noted, the veteran has recently indicated he is not seeking secondary service connection based on a direct causation theory. Some of the medical statements he has submitted have been offered in support of the Allen aggravation theory of secondary service connection, that his diabetes is aggravated by his service- connected PTSD. These medical statements collectively opine (with varying degrees of certainty) that psychiatric problems in general (or PTSD in particular) may adversely affect numerous physical ailments (or diabetes in particular). Many of the statements do not focus on the veteran's individual case, and some of the statements are by health care professional who are not physicians and lack competence to provide a medical opinion on secondary service connection for diabetes. Black v. Brown, 10 Vet.App. 279 (1997). The veteran's own lay statements on diagnosis and causation likewise lack competence. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Perhaps most importantly, none of the medical statements submitted by the veteran make any effort to identify and quantify (in terms which could practicably be applied to the rating schedule criteria for diabetes, 38 C.F.R. § 4.119, Code 7913) a component of his diabetes which is thought to be the result of aggravation from the PTSD. The medical statements provide generic, speculative, and equivocal assertions that anyone's PTSD or the veteran's PTSD may have an adverse impact on diabetes, that PTSD sometimes makes it difficult to control diabetes, that PTSD may exacerbate diabetes, etc. What the medical statements fail to do is offer any solid information identifying and quantifying an increment of the veteran's own diabetes which might be traceable to his PTSD. Even assuming that there are epidodes of increased diabetes symptoms because of PTSD, there is no probative medical evidence that the underlying disease of diabetes has advanced from its baseline level, as opposed to intermittent flare-ups of symptoms, due to the PTSD. See Hunt v. Derwinski, 1 Vet.App. 292 (1991) (in a claim for service connection based on aggravation of a preservice condition, temporary or intermittent flare-ups during service are not sufficient to be considered service aggravation, unless the underlying condition, as contrasted to symptoms, is worsened). Despite the vehemence of some of the medical statements submitted by the veteran, none of them pinpoints an increment of his chronic diabetes which is attributable to his PTSD. Nowhere in the record is there persuasive medical evidence that the current level of his diabetes is greater than if he did not have PTSD. While the medical evidence submitted by the veteran offers some support for his claim of secondary service connection, careful review of such evidence indicates it is but weak support, outweighed by other medical evidence which demonstrates that his diabetes was neither caused nor aggravated by his service-connected PTSD. The Board finds that the preponderance of the evidence is against the claim for secondary service connection for diabetes mellitus. Thus, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER Secondary service connection for diabetes mellitus is denied. L. W. TOBIN Member, Board of Veterans' Appeals