Citation Nr: 1123181 Decision Date: 06/16/11 Archive Date: 06/28/11 DOCKET NO. 04-35 631 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for carpal tunnel syndrome of the left wrist. REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had active service from May 1976 to July 1983. This matter originally came before the Board of Veterans' Appeals (Board) from an April 2003 decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case was previously before the Board in November 2007, and was remanded for procedural and evidentiary development. This case came before the Board again in August 2009, and was remanded for additional development. As will be discussed further herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the previous remand orders and that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). As noted by the Board in August 2009, in a statement dated in June 2009, the Veteran claimed that her service-connected genitourinary disorders led to her hysterectomy in November 2005. That claim has not been developed for consideration by the Board and it is referred to the agency of original jurisdiction (AOJ) for appropriate action. The Board further observed that, in her September 2004 substantive appeal, the Veteran asserted that her service-connected ear infections were worse and that the ringing in her ears should be considered. Ringing in the ears, or tinnitus, is a separate disability for which service connection has not yet been determined. Therefore, the claims for service connection for a hysterectomy and tinnitus as well as the claim for an increased rating for chronic otitis media are again referred to the AOJ for appropriate action. Recent case law mandates that a claim for a psychiatric disorder includes any psychiatric disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Given the holding in Clemons, the Board has characterized the issue as entitlement to service connection for an acquired psychiatric disorder as shown on the first page of this decision. FINDINGS OF FACT 1. There is clear and unmistakable evidence that posttraumatic stress disorder (PTSD) related to childhood trauma pre-existed the Veteran's entrance to active duty military service. 2. There is clear and unmistakable evidence that the Veteran's PTSD related to childhood trauma did not permanently increase in severity beyond the nature progression of the disease in active duty military service. 3. The competent and probative evidence of record fails to show that PTSD due to childhood trauma was aggravated by the Veteran's active duty military service. 4. The competent and probative evidence of record fails to show that an acquired psychiatric disorder, to include PTSD, is related to the Veteran's active duty military service, to include a verified stressor, and a psychosis did not manifest within one year of her service discharge. 5. The competent and probative evidence of record fails to show that the Veteran's carpal tunnel syndrome of the left wrist is related to her active duty military service. CONCLUSIONS OF LAW 1. The presumption of soundness is rebutted and PTSD related to childhood trauma pre-existed the Veteran's entry to active duty military service. 38 U.S.C.A. § 1111 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304(b) (2010). 2. PTSD related to childhood trauma was not aggravated by the Veteran's active duty military service. 38 U.S.C.A. §§ 1131, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2010). 3. An acquired psychiatric disorder, to include PTSD, was not caused by the Veteran's active duty military service nor may it be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1112, 1131, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2010). 4. Carpal tunnel syndrome of the left wrist was not caused by the Veteran's active duty military service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002& Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide, in accordance with 38 C.F.R. § 3.159(b)(1). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the duty to notify was satisfied by way of letters sent to the Veteran in September 2001 and October 2002, prior to the initial AOJ decision in this matter, and in August 2003 that fully addressed all of the notice elements. The letters informed her of what evidence was required to substantiate the claims and of her and VA's respective duties for obtaining evidence. The letters further advised her that her service connection claims must be supported by evidence indicating a current disability, evidence that the injury or disease was incurred or aggravated during service, and evidence of a nexus between the current disability and the in-service injury or disease. The Veteran was also notified of her and VA's respective responsibilities in obtaining evidence in support of her claims. Pertinent to the Veteran's claim of entitlement to service connection for PTSD, the Board further observes that, in connection with the October 2002 letter, the Veteran was advised that she could identify any sources, military or non-military, that may provide information concerning the incident(s), to include a rape crisis center, counseling facility or health clinic, or any military, police, or other authorities. Additionally, she was informed that, if she confided in a roommate, family member, chaplain, clergy, or fellow service person, such individual could submit a statement concerning their knowledge of the incident(s). Moreover, the Veteran was advised that she should indicate whether she experienced any of the following: visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; sudden request for change in Military Occupational Specialty or duty assignment; increased use of leave without immediate reason; changes in performance evaluations; episodes of depression, panic attacks, or anxiety; increased or decreased use of prescription medication; alcohol or substance abuse; increased use of over the counter medication; disregard for military or civilian authority; obsessive behavior such as overeating or undereating; tests for HIV or sexually transmitted diseases; unexplained economic or social behavior changes; or pregnancy tests around the time of the incident. Therefore, the Board finds that the Veteran was advised that evidence from sources other than her service records or evidence of behavior changes may constitute credible supporting evidence of the stressor, and allowed the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. See 38 C.F.R. § 3.304(f)(4); Bradford v. Nicholson, 20 Vet. App. 200, 206 (2006); Patton v. West, 12 Vet. App. 272, 278 (1999). With respect to the Dingess requirements, in January 2008, the AOJ provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish effective dates. With that letter, the AOJ effectively satisfied the remaining notice requirements with respect to the issues on appeal. Although complete notice, to include the Dingess elements, was not provided prior to the initial AOJ decision, the claims were subsequently readjudicated in the July 2004, May 2009, and March 2011 Supplemental Statements of the Case. Thus any timing error was cured by the readjudication of the claims. See Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370 (2006). Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of her case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting her in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Specifically, the AOJ has obtained VA medical records and Social Security Administration (SSA) records, which were identified in the November 2007 Board remand. In addition, she was afforded VA medical examinations, most recently in August 2010, which provided specific medical opinions pertinent to the issues on appeal. In this regard, as will be discussed further herein, the Board finds that the July 2008, and August 2010 VA examinations obtained in this case are more than adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. The opinions considered all of the pertinent evidence of record, to include VA and private treatment records, and the statements of the Veteran, and provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and/or opinion with respect to the issues on appeal has been met. The Board observes that this case was remanded in November 2007 and August 2009 in order to obtain SSA records and VA treatment records, and afford the Veteran VA examinations. As discussed in the preceding paragraphs, all requested development has been completed. Therefore, the Board finds that the AOJ has substantially complied with the November 2007 and August 2009 remand directives such that no further action is necessary in this regard. See D'Aries, supra. Moreover, neither the Veteran nor her representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Applicable Law Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A Veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Only such conditions as are recorded in examination reports are considered as noted. 38 C.F.R. § 3.304(b). History of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 03-2003; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). In deciding a claim based on aggravation, after having determined the presence of a pre-existing condition, the Board must first determine whether there has been any measured worsening of the disability during service and then whether this constitutes an increase in disability. See Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. 1153; 38 C.F.R. 3.306. Temporary or intermittent flare-ups of the pre-existing condition during service are not sufficient to be considered aggravation unless the underlying condition, as contrasted to symptoms, has worsened. Crowe v. Brown, 7 Vet. App. 238, 247- 48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). Accordingly, "a lasting worsening of the condition" -- that is, a worsening that existed not only at the time of separation but one that still exists currently -- is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including psychosis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.384, the term "psychosis" is defined so as to include brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. Service connection for PTSD requires a medical diagnosis of the disorder; credible supporting evidence that the claimed in-service stressful events actually occurred; and a link, as established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f). As the Veteran's alleged stressors are unrelated to combat or to fear of hostile military or terrorist activity, her lay testimony, by itself, is insufficient to establish the occurrence of the alleged stressor. Instead, the record must contain credible supporting evidence that corroborates the Veteran's testimony or statements. See Cohen v. Brown, 10 Vet. App. 128, 142 (1997). In cases of personal assault, under 38 C.F.R. § 3.304(f)(3), supporting evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: Records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in the sources. Examples of behavior changes that may constitute credible evidence of a stressor include, but are not limited to: Request for transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavioral changes. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Acquired Psychiatric Disorder The Veteran contends that she currently has an acquired psychiatric disorder, to include PTSD, due to events that occurred during service. Specifically, in a February 2003 response to PTSD questions provided by the AOJ, the Veteran claimed that she has PTSD due to personal assault, including being raped, physical abuse, being whipped with a coat hanger, being beaten, and having a knife to her throat. She indicated that she did not report any of the incidents to anyone or any facility. The Veteran also reported that a service member once put his hand on her "private parts." In a December 2008 statement, she claimed that she was diagnosed and treated for Chlamydia and pelvic inflammation in service. In a November 2003 statement, the Veteran reported that she had been informed that she had herpes I and II, and wished for that information to be used to support her claim. In her September 2004 VA Form 9, she stated that during service she had "female problems" related to sexual abuse and that she was beaten, sexually abused, and raped in service. In a February 2003 statement, the Veteran reported that her harassment began while in Germany and lasted throughout the course of her military career. She indicated that she was drinking a lot and was date raped several times, and that she was first introduced to drugs in service. She also stated that she had a bad reputation while in Germany, which led her to become a "workaholic" to earn respect at work. She also indicated that she started a relationship with a married man at that time, which was abusive and included an incident when her boyfriend held a knife to her neck. As such, the Veteran has claimed that she was physically and sexually assaulted while performing normal duties in Germany, from November 1976 until August 1979, as indicated in her February 2003 stressor statement. She also reported that she underwent behavioral changes following her claimed assaults, including episodes of depression, panic attacks, or anxiety; an increased alcohol or substance abuse; increased use of over the counter medication; obsessive behavior such as overeating or under eating; sexually transmitted diseases tests; unexplained economic or social behavior changes; and pregnancy tests around the time of the incident. Over the course of her appeal, she has also subsequently claimed to have experienced various other non-specific assaults that occurred while stationed in Virginia and Hawaii. The Board notes that the Veteran's service treatment records reflect that a March 1976 examination, provided prior to her entry to service, found her to be psychiatrically normal, as did her September 1983 separation examination. Additionally, her service treatment records are silent as to any complaints of, or treatment for, any kind of psychiatric disorder. However, they do indicate that she made complaints regarding vaginal discharge, as in November 1978, and was repeatedly treated for urinary tract infections. One gynecological examination, which indicated that the first day of her last menstrual period was May 1977, indicated that she was on birth control pills. As the Veteran's service entrance examination failed to note a diagnosed acquired psychiatric disorder, the presumption of soundness attaches. However, the Board finds that there is clear and unmistakable evidence that PTSD related to childhood trauma existed prior to service and was not aggravated by service. Therefore, the presumption of soundness is rebutted and PTSD related to childhood trauma pre-existed the Veteran's entry into active duty military service. In this regard, July 2008 and August 2010 VA examiners found the Veteran's stressors to involve sexual and non-sexual personal assault, which occurred during her childhood, before military service. The examiners also determined that although she met Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV), stressor criteria for PTSD, it was less likely as not (50/50 probability) caused by or aggravated by military service. In this regard, the Board notes that both physicians reviewed the Veteran's records, to include her service treatment records, and applied the relevant medical principles in finding that her PTSD was due to her pre-service stressors. With respect to the August 2010 VA examination, the examiner found that the Veteran's PTSD related to childhood trauma pre-existed her military service. Specifically, he indicated that the Veteran's PTSD onset was from severe abuse in childhood. The examiner reported that the Veteran had significant history of childhood emotional, sexual, and physical abuse that more likely than not brought about the onset of PTSD. The VA examination in July 2008 also included a review of the claims file. At such time, the Veteran reported that her mother received a lobotomy 6 months prior to her birth and was ill throughout her life; she claimed a horrific childhood due to her parents and that she was mentally ill due to her mother. She reported significant childhood abuse, including physical and sexual abuse on several occasions. The Veteran also indicated that she was molested as a child in her church, by her father, and by neighborhood boys. Based on a review of the claims file, an interview with the Veteran, and a mental status examination, the July 2008 VA examiner determined that the Veteran had stressors involving sexual and non-sexual personal assault, which occurred during her childhood, before military service. The examiner further noted that the Veteran did not endorse any military-related or post-military traumatic events. The examiner opined that the Veteran met DSM-IV stressor criteria for PTSD due to childhood physical and sexual abuse. The examiner further found that the Veteran had chronic PTSD that was not caused by or a result of military service and was less likely as not (50/50 probability) aggravated by military service. The examiner indicated that his opinion was based on the Veteran's military records, a review of the claims file and treatment records, clinical evaluation, review of recent research, and the DSM-IV diagnostic criteria. The Veteran has also repeatedly reported her stressors when seeking psychiatric treatment from VA; however, when doing so, she generally only reported her pre-service stressors. In this regard, a March 21, 2003, VA medical record noted that she complained of daily harsh physical punishment from her parents and an attempted rape by her father, as well as other pre-service rapes, but did not report any in-service stressors. That VA examiner found her to have PTSD due to childhood/adulthood cumulative trauma. Subsequent VA medical records similarly and repeatedly found her to have PTSD due to childhood and adulthood neglect or physical abuse. Although some VA medical records, such as December 12, 2003, and May 12, 2004, records, did note a history of marital and military service trauma, they also found her to have PTSD due to childhood trauma or PTSD due to childhood/military combined emotional and sexual trauma. In this regard, although the Federal Rules of Evidence do not apply to Veterans' jurisprudence, recourse to the Federal Rules of Evidence is appropriate where the Rules assist in the articulation of the Board's reasons and bases for a decision in a given case. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997); Cf. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (finding Federal Rules of Evidence may supply guiding factors to be used by VA adjudicators in evaluating the probative value of medical evidence). Here, the Board finds Rule 803 of the Federal Rules of Evidence to be instructive as this Rule provides an exception to hearsay rules with regard to statements made for the purpose of medical diagnosis or treatment. This Rule acknowledges that there is a particular self-interest or need for honesty inherent in providing statements to medical personnel while seeking treatment, i.e., that the Veteran had significant personal cause to be honest and complete in describing her medical history at the time that she sought treatment. Therefore, the Board accords great probative weight to the Veteran's own statements when seeking medical treatment that her PTSD stressors existed since childhood. Based on the objective evidence of record, to specifically include the July 2008 and August 2010 VA examinations, as well as the Veteran's own statements, as submitted by her and recorded by health professionals, the Board finds that the Veteran's PTSD related to childhood trauma clearly and unmistakably existed prior to her military service. However, with respect to rebutting the presumption of soundness, as noted previously, the Board's inquiry does not end with a determination that the Veteran's PTSD related to childhood trauma clearly and unmistakably pre-existed service. The Board must also determine whether the Veteran's pre-existing PTSD related to childhood trauma was aggravated during service. In this regard, the Veteran's service treatment records do not indicate any complaints, treatment, or diagnoses referable to a psychiatric disorder and her post-service private medical records are silent as to PTSD for a number of years following her discharge from service. Additionally, the July 2008 and August 2010 VA examiners found that PTSD was not aggravated by service. Specifically, the July 2008 VA examiner opined that the Veteran's PTSD was less likely as not (50/50 probability) aggravated by military service. He indicated that his opinion was based o n the Veteran's military records, review of the claims file, treatment records, clinical evaluation, review of recent research, and DSM-IV diagnostic criteria. Additionally, after reviewing the claims file, interviewing the Veteran, and conducting a mental status examination, the August 2010 VA examiner determined that it was less likely as not (less than 50/50 probability) that any pre-existing acquired psychiatric disorder increased in severity during the Veteran's active service. In this regard, he noted that the Veteran was not treated for symptoms of a psychiatric disorder until after approximately two years following her discharge and that her in-service personnel records were exemplary and service treatment records did not indicate mental health treatment. As the July 2008 and August 2010 VA examiners based their opinions on a complete review of the Veteran's claims file, to include her lay statements, in-service and post-service treatment records and personnel records, and referenced other information that he deemed to be important, the Board finds that such opinions contains clear conclusions with supporting data, and a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, the Board accords such opinions great probative weight. There is no medical opinion to the contrary. Insofar as the Veteran herself has alleged that her pre-existing PTSD related to childhood trauma was aggravated by her military service, the Board notes that lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet.App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's PTSD related to childhood trauma and her military service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992). Therefore, while the Veteran is competent to describe the observable symptoms of her PTSD, the Board accords her statements regarding whether such disease increased in severity beyond the natural progression to be of little probative value as she is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Moreover, the Veteran has only offered conclusory statements regarding the relationship between her PTSD related to childhood trauma and her military service. In contrast, the July 2008 and August 2010 VA examiners took into consideration all the relevant facts in providing their opinions. Therefore, the Board finds that the Veteran's contentions regarding the aggravation of her PTSD related to childhood trauma are outweighed by the competent and probative July 2008 and August 2010 VA examiners' findings. Therefore, based on the competent and probative evidence of record, the Board finds that there is clear and unmistakable evidence that the Veteran's PTSD related to childhood trauma did not permanently increase in severity beyond the natural progression in service. As such, the Board concludes that there is clear and unmistakable evidence that the Veteran's PTSD related to childhood trauma existed prior to service and was not aggravated by service. Consequently, the presumption of soundness has been rebutted and the Veteran's PTSD related to childhood trauma pre-existed service. Additionally, for the same reasons discussed above, the Board finds that, based on the competent and probative evidence of record, to specifically include the July 2008 and August 2010 VA examiners' opinions, the Veteran's pre-existing PTSD related to childhood trauma was not aggravated by her military service. The Board further finds that the competent and probative evidence of record fails to show that an acquired psychiatric disorder, to include PTSD, is related to the Veteran's active duty military service, to include a verified stressor, and a psychosis did not manifest within one year of her service discharge. With respect to the Veteran's claim that she has PTSD related to military stressors in addition to as a result of childhood trauma, the Board finds that, based on the evidence as a whole, to include her allegations of behavior changes and treatment for STDs, that such allegations are not credible and, therefore, her claimed in-service stressors are not verified. In this regard, the Veteran's service treatment records indicate that she made complaints regarding vaginal discharge, as noted in November 1978, and was repeatedly treated for urinary tract infections. Additionally, it was noted that she was on birth control pills. However, such do not reflect testing for STDs as she has claimed. Moreover, the Veteran's service treatment and personnel records do not reflect a change in personality as she has claimed. Following her service in Germany, she received a promotion. Additionally, an April 1980 Enlisted Evaluation Report recommended that she be promoted ahead of her peers and be assigned to positions with greater responsibility. The record further indicates that her superiors found her to do outstanding work, as indicated in a July 1981 Letter of Commendation, an August 1982 Good Conduct Medal award, and a September 1982 Recommendation for Discharge indicating that she requested discharge due to her son's physical problems and the recommendation of a grant of an honorable discharge. Therefore, the evidence of record does not support the verification of the Veteran's claimed stressors and, as such, the Board finds her allegations to lack credibility. In this regard, the service records do not indicate that the Veteran's behavior changed following her claimed stressor. Rather, she was promoted during the period of time some of the claimed stressors occurred and no adverse personnel action was indicated in her records. Her service was also repeatedly found to be commendable over the course of her service. The Board is cognizant that medical opinions in cases of personal assault for PTSD are exceptions to the general rule discussed in Moreau v. Brown, 9 Vet. App. 389, 396 (1996), that an opinion by a medical professional based on a post-service examination cannot be used to establish the occurrence of a stressor. See Patton v. West, 12 Vet. App. 272, 277 (1999); see also 38 C.F.R. § 3.304(f)(3); VA Adjudication Procedure Manual, M21-1MR, Part III, Subpart iv, Chapter 4, Section H, part 30(b), (c), (e) (Aug. 1, 2006). However, in the instant case, although the Veteran reported in-service stressors during the August 2010 VA examination, the examiner found her PTSD to be less likely as not caused by or a result of trauma during service. In this regard, the examiner discussed her claimed stressors, including one involving another serviceman, which did not include intense fear, feeling of hopelessness, or a feeling of horror, because she reported that she had been "too drunk to be scared." The Veteran also reported that she had "a lot of sexual stuff going on in the military," including a service member putting his "hands down my crotch," after which she reported that the offender was punished. She further discussed her drinking and multiple sex partners, as well as sex dreams, and getting date raped and raped. She further claimed that her child's father once beat her with a bent coat hanger until her back was black and blue, though she stayed with him for several more years and that he continued to hit her several times after that incident. She stated that she did not seek medical treatment, except one time when he twisted her wrist. After considering the Veteran's alleged military stressors, the examiner determined that her PTSD was less likely as not (less than 50/50 probability) caused by or a result of trauma during service. In this regard, the August 2010 VA examiner further explained that the Veteran was not treated for symptoms of a psychiatric disorder until approximately two years following her discharge and that her in-service personnel records were exemplary and service treatment records did not indicate mental health treatment. Therefore, the Board finds that the Veteran does not have PTSD related to her military service, to include a verified stressor. Additionally, while she has not specifically claimed that she has an acquired psychiatric disorder other than PTSD that was caused by service, the Board has also considered such as part of the current claim. See Clemons, supra. In this regard, the Board observes that the Veteran has been diagnosed with several acquired psychiatric disorders, other than PTSD, since her discharge from service, to include bipolar disorder, a delusional disorder, and schizoaffective disorder; however, the most recent VA examinations conducted in July 2008 and August 2010 specifically found the Veteran to only have current diagnoses of PTSD, delusional disorder, and schizoaffective disorder. The Board is cognizant of the Court's holding in McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), which provides that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim. However, in the instant case, the Board finds that the VA examinations are the most probative evidence of record with respect to the Veteran's current psychiatric disorders as the examiners reviewed the record in full, which includes documentation of the Veteran's prior diagnoses, and specifically determined that she met the DSM-IV criteria for PTSD, delusional disorder, and schizoaffective disorder. In this regard, the Board notes that the July 2008 VA examiner provided an Axis I diagnosis of PTSD and delusional disorder, and noted that, while the Veteran had a history of a diagnosis of schizoaffective disorder, her history was more consistent with the diagnoses he provided rather than schizoaffective disorder. However, as the August 2010 VA examination is the most recent and comprehensive evaluation of the Veteran's acquired psychiatric disorders, the Board finds that the Veteran has a diagnosis of schizoaffective disorder in addition to PTSD and delusional disorder. Therefore, the Board has considered whether the Veteran's acquired psychiatric disorder, other than PTSD, which has been diagnosed as delusional disorder and schizoaffective disorder, is related to her military service. The Board initially finds that the Veteran did not have an acquired psychiatric disorder in service or within one year of her discharge from service. Specifically, her service treatment records are silent as to any complaints, treatment, or diagnoses referable to any psychiatric disorder, as is the record for the year following her discharge from service. The first evidence of record for treatment for a psychiatric disorder are dated in 1987, several years following her 1983 discharge from service, as indicated in a June 9, 1987, Boley Manor medical report, which noted that she had first sought mental health treatment in 1986. As such, service connection on a presumptive basis for a psychosis is not supported by the evidence of record. Moreover, the competent and probative evidence fails to demonstrate that the Veteran has an acquired psychiatric disorder that developed in or was caused by her service. In this regard, the Board observes that the July 2008 VA examiner opined that the Veteran's delusional disorder was not caused by or a result of military service. He indicated that his opinion was based on the Veteran's military records, review of the claims file, treatment records, clinical evaluation, review of recent research, and DSM-IV diagnostic criteria. Additionally, in August 2010, the VA examiner opined that the Veteran's schizoaffective disorder was less likely as not caused by or due to service. The August 2010 VA examiner also provided a reasoning on how he reached his conclusions, including consideration of service treatment records, post service psychiatric treatment, and the Veteran's significant family history for psychiatric disorders. Thus, in regard to a claim for service connection for an acquired psychiatric disorder, other than PTSD, given that the record does not indicate that the Veteran developed such an acquired psychiatric disorder in service or within a year of her discharge from service, and since the most competent and probative medical evidence of record has determined that such disorders are not due to service, service connection for an acquired psychiatric disorder, other than PTSD, is not warranted. To the extent that the Veteran contend that any of her claimed acquired psychiatric disorders, to include PTSD, were caused by her military service, the Board again finds that the question regarding the potential relationship between the Veteran's acquired psychiatric disorders and her military service to be complex in nature. See Woehlaert, supra; Richardson, supra. Therefore, while the Veteran is competent to describe the observable symptoms of her acquired psychiatric disorders, the Board accords her statements regarding the etiology of such disease little probative value as she is not competent to opine on such complex medical questions. See Jones, supra. Moreover, the Veteran has only offered conclusory statements regarding the relationship between her acquired psychiatric disorders and her military service. In contrast, the July 2008 and August 2010 VA examiners took into consideration all the relevant facts in providing their opinions. Therefore, the Board finds that the Veteran's contentions regarding the etiology of her acquired psychiatric disorders are outweighed by the competent and probative July 2008 and August 2010 VA examiners' findings. Moreover, to the extent that the Veteran has contended that she has experienced psychiatric symptomatology since her service discharge, the Board finds such statements to lack credibility and, therefore, accords no probative weight to such contention. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has determined that the Veteran's statements regarding continuity of symptomatology to be not credible as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest. While the Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, the Board may, however, in the present case, consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). In this regard, the Board notes that the Veteran's service treatment records are negative for any complaints, treatment, or diagnoses of an acquired psychiatric disorder and the post-service treatment records reflect that the first evidence of record for treatment for a psychiatric disorder are dated in 1987, several years following her 1983 discharge from service, as indicated in a June 9, 1987, Boley Manor medical report, which noted that she had first sought mental health treatment in 1986. The Board therefore finds that the Veteran's current statements, made in connection with her pending claim for VA benefits, that she has had psychiatric symptomatology since service are inconsistent with the contemporaneous evidence. Thus, the Veteran's lay assertions of continuity of psychiatric symptomatology are less credible and persuasive in light of the other evidence of record, and are, in fact, outweighed by this evidence. Therefore, the Board finds that service connection is not warranted for an acquired psychiatric disorder. In reaching this determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C.A. § 5107. Carpal Tunnel Syndrome of the Left Wrist The Veteran contends that she has had carpal tunnel syndrome of the left wrist since her military service and, as such, service connection is warranted. The Veteran's service treatment records are silent as to any complaints, treatment, or diagnoses referable to carpal tunnel syndrome of the left wrist. Her March 1976 examination, prior to her entry to service, found her upper extremities to be normal. Likewise, her June 1983 separation examination found her upper extremities to be normal, except for a ganglion cyst of the right wrist. The record is also silent as to any complaints, treatment, or diagnoses referable to carpal tunnel syndrome for over a decade following the Veteran's service discharge. A September 24, 2001, private medical record, by Dr. M.S., noted that she complained of numbness/tingling in the left hand, and found her to have diabetes mellitus/neuropathy. A February 2003 VA examination noted that the Veteran complained of tingling and numbness of the hands and fingers, and claimed to have bilateral carpal tunnel syndrome. The examiner noted that she complained of neuropathy, mostly to her hands, and contractures of the left digits. The examiner found the Veteran to have a history of carpal tunnel syndrome, and that examination showed mostly to the left wrist with secondary contracture of the fingers. However, the examiner did not provide an opinion as to the etiology of the carpal tunnel syndrome. The Veteran received another VA examination in June 2008, which included a claims file review. She reported that her carpal tunnel syndrome began in 1983, and that she had some tingling and numbness in her left hand while stationed in Hawaii, but that she did not seek medical help and that she has still not yet complained to her doctors. She complained of current left hand numbness, pain, and tingling. The June 2008 VA examiner found the Veteran to have mild left carpal tunnel syndrome and noted that it had no etiology. However, the examiner opined that it is at least as likely as not that the carpal tunnel syndrome of the left wrist began during her service. The Veteran was provided another VA examination in August 2010, which also included a claims file review. This time, the Veteran reported that her carpal tunnel syndrome began in 1980, and claimed that she was diagnosed with a cyst of the right wrist in service, but never sought attention after service. She then claimed that 3 to 4 years previously she had pain in the right wrist and sought medical attention. She complained of pain bilaterally of the wrists, fingers, and hands. The examiner found tests to indicate that the Veteran had bilateral moderate carpal tunnel syndrome of the upper extremities. The examiner also noted that the Veteran indicated that she was a left handed painter and did not want surgery since it might affect her ability to paint. The examiner further noted a history of diabetes mellitus, and tingling and numbness of both hands and feet. The August 2010 VA examiner found service treatment records to indicate treatment for a right wrist cyst, but that they were silent regarding the left wrist for a cyst or carpal tunnel syndrome. The examiner found it to be less likely as not that carpal tunnel syndrome was the same as or due to service. The examiner noted no mention of a left wrist ganglion cyst/carpal tunnel syndrome in the service treatment records or in the service history. VA medical records and private medical records are generally silent as to any complaints, treatment, or diagnoses referable to left carpal tunnel syndrome. Indeed, as noted by the Veteran in her VA examinations, she has not sought treatment for that disorder. The Board recognizes that the record contains competing medical opinions as to the diagnosis of the Veteran's current carpal tunnel syndrome claim. The Board must thus determine how much weight to afford the opposing opinions. See Guerrieri v. Brown, 4 Vet. App. 467, 471 (1993). The Board may weigh one medical professional's opinion over another, depending on factors such as the reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior evidence. Id. at 470-71. ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusions that the physician reaches"). The Board must provide adequate reasons and bases if it adopts one medical opinion over another. Owens v. Brown, 7 Vet .App. 429, 433 (1995) (noting that the Board may "favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases"). In this regard, the Board finds the August 2010 VA examiner's opinion to be more probative than the June 2008 VA examiner's opinion. Specifically, the August 2010 VA examiner included a discussion of the service treatment records and provided a basis for the negative opinion provided. In contrast, the June 2008 VA examiner did not indicate what records were reviewed and did not give an explanation as to how the opinion was reached. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight of the credibility of the evidence in the adjudication of the merits. See Hernanadez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The Board further notes that the August 2010 VA examiner provided a more in depth examination, with objective findings made and testing performed. As such, the Board finds the August 2010 VA examiner's opinion to be more probative than the June 2008 VA examiner's opinion and, as such, finds that the competent and probative medical evidence of record does not support the Veteran's claim. In the present case, the Veteran has claimed that she has had left hand numbness since service. However, to the extent that the Veteran has claimed a continuity of carpal tunnel syndrome since service, her lay evidence is outweighed by the competent medical evidence. Simply stated, the Veteran's service treatment records (containing no competent medical evidence of carpal tunnel syndrome) and post-service treatment records (showing no findings of carpal tunnel syndrome until September 2001), and the most probative competent medical evidence finding that it is not related to service outweighs the Veteran's contentions. Furthermore, the only evidence of the occurrence of in-service left wrist carpal tunnel syndrome is the Veteran's own relatively recent statements. In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility, and therefore the probative value, of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board finds that the service treatment records and the post-service medical treatment records to carry far more weight of credibility and probative value that the recent lay statements. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Such records are more reliable, in the Board's view, than the unsupported assertions of events now over 30 years, made in connection with her claim for monetary benefits from the government. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a Veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). The Board also notes that the Veteran has provided conflicting information regarding her claimed disability, which raises questions as to her credibility. For example, she provided different dates as to the onset for her carpal tunnel syndrome to her different VA examiners. The only other evidence provided as to the Veteran's claim is her belief that her carpal tunnel syndrome of the left wrist developed due to service. In this regard, the Board finds that the question regarding the potential relationship between the Veteran's carpal tunnel syndrome of the left wrist and her military service to be complex in nature. See Woehlaert, supra; Richardson, supra. Therefore, while the Veteran is competent to describe the observable symptoms of her acquired psychiatric disorders, the Board accords her statements regarding the etiology of such disease little probative value as she is not competent to opine on such complex medical questions. See Jones, supra. Moreover, the Veteran has only offered conclusory statements regarding the relationship between her carpal tunnel syndrome of the left wrist and her military service. In contrast, the August 2010 VA examiner took into consideration all the relevant facts in providing his opinion. Therefore, the Board finds that the Veteran's contentions regarding the etiology of her carpal tunnel syndrome of the left wrist are outweighed by the competent and probative August 2010 VA examiner's findings. Therefore, the Board finds that service connection is not warranted for carpal tunnel syndrome of the left wrist. In reaching this determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for carpal tunnel syndrome of the left wrist. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for carpal tunnel syndrome of the left wrist is denied. ______________________________________________ A. JAEGER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs