Citation Nr: 0001211 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 96-41 781 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a psychiatric disability, to include post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Kenneth B. Mason, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Acosta, Counsel INTRODUCTION The veteran served on active duty from June 1973 to April 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1995 rating decision of the Department of Veterans Affairs (VA) St. Petersburg, Florida, Regional Office (RO). The Board denied the benefit sought on appeal in a decision dated in April 1998, which the veteran then appealed to the United States Court of Veterans Appeals (known as the United States Court of Appeals for Veterans Claims since March 1999, hereinafter referred to as "the Court"). A Joint Motion for Remand and for a Stay of Proceedings was thereafter filed by the veteran's private attorney before the Court and the Secretary of VA in June 1999 and the Court granted the relief sought in July 1999, by vacating and remanding the Board's decision of April 1998 for adjudication consistent with the discussion in the Joint Motion. The matter on appeal is now back at the Board, ready for its re-adjudication. FINDING OF FACT The veteran, who served on active duty in the Republic of Vietnam during the Vietnam era but is not a combat veteran, has failed to objectively demonstrate that any currently- manifested psychiatric disability was incurred in or aggravated during service. CONCLUSION OF LAW The veteran has failed in his initial duty to submit a claim for service connection for a psychiatric disability, to include PTSD, that is well grounded or capable of substantiation. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR THE FINDING AND THE CONCLUSION Initial considerations, including the applicable VA laws and regulations: The threshold question that must be resolved at the outset of the analysis of any issue is whether the appellant's claim is well-grounded; that is, whether it is plausible, meritorious on its own, or otherwise capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has said that the statutory "duty to assist" under 38 U.S.C.A. § 5107(a) (West 1991) does not arise until there is a well- grounded claim. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The question of whether or not a claim is well-grounded is significant because if a claim is not well-grounded, the Board does not have jurisdiction to adjudicate that claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). An appellant has, by statute, the duty to submit evidence that a claim is well-grounded. The evidence must "justify a belief by a fair and impartial individual" that the claim is plausible. 38 U.S.C.A. § 5107(a) (West 1991). Where such evidence is not submitted, the claim is not well-grounded, and the initial burden placed on the appellant is not met. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In order for a claim for service connection to be well grounded, there must be competent evidence of a current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury during service (lay or medical evidence), and of a nexus between the inservice injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Evidentiary assertions by the appellant must be accepted as true for the purposes of determining whether a claim is well- grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). Where the issue is factual in nature, e.g., whether an incident or injury occurred in service, competent lay testimony, including an appellant's solitary testimony, may constitute sufficient evidence to establish a well-grounded claim under 38 U.S.C.A. § 5107(a) (West 1991). See Cartright v. Derwinski, 2 Vet. App. 24 (1991). However, where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. See Murphy, at 81. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). In addition to the above, service connection may be warranted on a presumptive basis if it is shown that any one of the diseases deemed by VA as chronic in nature, such as psychosis, was manifested to at least a 10 percent degree within the (usually) one-year period immediately following the veteran's separation from active military service, notwithstanding the lack of evidence of the manifestation of the disease during service. See, 38 C.F.R. §§ 3.307 and 3.309 (1999). No compensation shall be paid, however, if the claimed disability is the result of the claimant's own willful misconduct or, for claims filed after October 31, 1990, the result of his or her abuse of alcohol or drugs. See, 38 U.S.C.A. § 1110 (West 1991); and 38 C.F.R. §§ 3.301(a) (1999). While the isolated and infrequent use of drugs by itself will not be considered willful misconduct, the progressive and frequent use of drugs to the point of addiction, as well as their use to enjoy or experience their effects, will be considered willful misconduct. See, 38 C.F.R. § 3.301(c)(3) (1999). Additionally, mere congenital or developmental defects, refractive error of the eye, personality disorder and mental deficiencies are not diseases or injuries in the meaning of the applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9 (1999). Eligibility for a PTSD service-connection award requires the presence of the following three elements: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (1999); (2) a link, established by medical evidence, between current symptoms and an inservice stressor; and (3) credible supporting evidence that the claimed inservice stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1999); see also, Cohen v. Brown, 10 Vet. App. 128 (1997). As noted above, the burden placed on a claimant to prove the actual inservice incurrence or aggravation of the claimed disability or injury or, in the case of PTSD, the occurrence of the claimed stressors, is significantly reduced if there is competent evidence showing that the veteran was in fact engaged in combat with the enemy. This is not so, however, until that finding is made by the Board. See, Irby v. Brown, 6 Vet. App. 132, 136 (1994); see, also, Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). If the Board finds that the veteran did not engage in combat with the enemy, credible supporting evidence from any source showing that his claimed inservice stressor actually occurred would be required for him to prevail. Under such circumstances, his lay testimony regarding the stressors would thus be insufficient, standing alone, to establish service connection. See, in this regard, Moreau v. Brown, 9 Vet. App. 389, 394-395 (1996); and Doran v. Brown, 6 Vet. App. 283, 290 (1994). Even if the record contains a clear, unequivocal PTSD diagnosis, that diagnosis satisfies only one of the Caluza elements required in order for service connection for PTSD to be awarded. "There must also be evidence establishing the occurrence of the stressor...and medical evidence to link the stressor to the current symptomatology....An opinion by a mental health professional based on a post-service examination of the veteran cannot be used to establish the occurrence of the stressor." Cohen, at 24. Factual and procedural background: At the outset, the Board must note that the record shows that the veteran served in the Republic of Vietnam during the Vietnam era and that he was awarded the National Defense Service Medal, the Vietnam Service Medal and the Vietnam Commendation Medal. However, none of these medals indicate combat duty and there is no other competent evidence in the record showing that the veteran is a combat veteran. A review of the veteran's service medical records reveals that, while the veteran had a negative psychiatric evaluation and denied ever having had, or currently having, depression or excessive worry and nervous trouble of any sort upon induction in April 1973, he did say, in a report of medical history that he filled out and signed less than a year later, in January 1974, that he had had, or was currently having, depression or excessive worry, as well as periods of unconsciousness. The examiner who signed this report clarified the veteran's statement, however, by saying that the veteran had been depressed "prior to entering [the] Navy," and it is noted that the report of a medical examination that was conducted on the same date again reveals a normal psychiatric evaluation of the veteran. An August 1974 service medical record reveals that the veteran admitted a four-year (i.e., pre-service) history of drug abuse, saying that he had used "amphetamines, barbiturates, hallucinogens, etc, almost daily at various times." The subscriber of this entry then stated that it was his or her impression that the veteran needed to enter a drug rehabilitation program "because of his demonstrated psychological dependence on mood changing drugs." The report of a medical examination that was conducted in September 1974 reveals, again, a normal psychiatric evaluation of the veteran. It also indicates that the veteran had a drug history that included intravenous use of "methadrine" and heroin, and oral use and inhalation of multiple ("poly") drugs. An undated report of medical history that seems to have been produced at about the same time reveals complaints of having had, or currently having, frequent trouble sleeping, depression or excessive worry, and periods of unconsciousness. However, the veteran denied in this report having had, or currently having, nervous trouble of any sort, and stated that his health was good, with no major illness or medical problems within the past six years, although he admitted having been treated at the "Balboa Naval Hospital" for detoxification. According to a psychiatric interview questionnaire that the veteran filled out in March 1975, the veteran described his father's personality as hostile, aggressive and suppressed, and his mother's personality as expressing insecurity. He said that he did not get along with either parent, which was not the case with his brother and sister, and described his home environment during childhood and adolescence as a "broken home," the result of which he had had to spend time as a teenager in a "boys' home." He further said that he had suffered from cramps at age 16, fainting and insomnia at age 17, frightening dreams at age 10, and depressions "most of the time," as well as dizziness, sick headaches and stammering. He acknowledged a moderate use of alcohol and described his experience in the service as "fair," adding that he liked his "rate" but that he disliked the regulations. He described himself as a follower, rather than a leader, a "lone wolf" and a timid person in crowds, and briefly described his problem as feeling depressed and tense and having frequent headaches and suicidal urges. According to the subscriber of a March 1975 handwritten statement, presumably a mental health specialist, the veteran had had "many hang ups dealing with his moral values," had problems differentiating between "natural body drives" and what the church considered "sins," and had apparently rebelled against life because of the "dirty deal" he thought he had gotten from life. The subscriber of this statement said, however, that he saw potential in the veteran, if given proper guidance. A service medical record also dated in March 1975 reflects the veteran's visit to the medical department of the ship to which he was assigned at the time, the USS Kitty Hawk. According to this record, the veteran complained of constant depression and a feeling of worthlessness, and said that he had just been discharged from the Naval Drug Rehabilitation Center at Miramar, California, after having been hospitalized at the Naval Hospital in Balboa for an attempted suicide ("an overdose"). The veteran said that he had behaved as an immature child at the Rehabilitation Center, that he felt that he was not able to change and that, upon his return to the ship, he had been assigned to "mess cooking" and had had repeated confrontations with his immediate supervisors. It was noted that the veteran's family history was "significant in the fact that his parents are separated," that he felt estranged from both parents and that he reported constant friction between him and his father, as well as between him and his mother. He reported having had a drug problem in high school that progressively became worse as he entered the Navy, and described his adolescent life as "one of turmoil with several foster homes being involved." In the subscriber's opinion, there was a strong possibility that the veteran used drugs on occasion "to escape." The above report further shows that the mental status examination was "essentially normal with the exception of a strong depression" and a bland affect, as the veteran was not psychotic or neurotic, and was oriented to time, place and person. He had the ability to shut off conversation that he regarded as irrelevant, and this occurred frequently throughout the interview. He was not particularly hostile, but resigned and bitter. The subscribing physician concluded that the veteran showed "a strong history of drug abuse"; that he was immature and showed "significant signs of long standing adjustment problems related to a difficult family situation"; that it was apparent that he was undergoing "a significant depressive reaction at this time" of which his drug abuse "could be a significant component"; that there was a significant indication that he would respond to counseling and reinforcement therapy, if the opportunity were provided; that, accordingly, he would be counseled aboard the ship and would be followed closely during this depressive episode; and that, since his remaining interest in drugs was very important, it was felt that his use of drugs should be discouraged, if at all possible. The impressions were listed as a depressive reaction and an immature personality. A service medical record that was dated four days after the above medical consultation of March 1975 reveals a referral for a psychiatric evaluation and advice regarding the diagnosed "[i]mmature personality with depression secondary to [an] acute situational adjustment." According to this document, the veteran's medical record was not available and the veteran had stated that it was lost. According to copies of additional service medical records in the claims folder, while awaiting psychiatric evaluation for administrative separation from the service, the veteran went to a party in San Diego, California, took some drugs and then flew to San Francisco, on March 31, 1975, to see his sister, who brought him to a military hospital, where he was hospitalized for a few days. It was noted that he acknowledged having taken speed, acid and tetrahydrocannabinol ("THC") the day of the party and having "much prior drug use and inadaptability in the U.S. Navy," and that he had agreed that an administrative separation was warranted. On the day of the above admission, the veteran reportedly said that he blamed "this" (his overdose and related drug problems, apparently) on his parents' divorce when he was 15 years old and on his having joined the Navy, which took him away from his home security. On discharge from this admission, he was noted to be calm, oriented, and alert, with no signs of psychosis or neurosis, nor any suicidal or homicidal ideations or threats. The final diagnoses were listed as a non-psychotic organic brain syndrome ("OBS"), secondary to drugs, resolved; poly drug use; and an emotionally unstable personality, and an administrative separation was recommended. The report of the medical examination that the veteran underwent for separation purposes in April 1975 reveals, again, a normal psychiatric evaluation. It appears that the veteran was administratively (and honorably) separated, as recommended, although this cannot be determined for sure from the evidence of record. A review of the post-service medical evidence in the record reveals additional psychiatric treatment, starting in July 1976, when the veteran was admitted to a private medical institution for four days after a suicidal gesture, and was described on admission as being angry, hostile and uncooperative, and to be complaining of being "pissed off." Depression, associated with an immature personality, was diagnosed. Private medical records that were dated in January 1980 reveal two medical consultations due to depression, and objective findings, on the second consultation, of a depressed mood, with a paranoid thought content and affect, but with no hallucinations or delusions. These documents also reveal that the veteran was released to his parents, since he was both unwilling and unable to seek voluntary admission. A VA outpatient medical record also dated in January 1980 reflects a medical consultation due to the veteran's reported intentions to kill himself and others, basically due to his feeling that he had failed at everything in life. He was described as withdrawn and preoccupied during the interview, with some paranoid thinking, but no hallucinations, and questionable ("?") paranoid delusions. The examiner was unable to elicit any precipitating factors, although he made reference to the veteran's problems with his parents' being divorced and his feeling that his mother didn't like him. The assessment was listed as rule out ("R/O") psychotic depression and rule out a thought disorder. A July 1980 private medical record reflects a six-day hospitalization due to hostile and "seclusive" behavior. Initially, the veteran had complained of auditory hallucinations, but he later denied them, stating that it had been a ploy to get into the hospital. It was noted that there was "[n]o evidence of organicity" and that the veteran had made several demands upon the staff and had behaved in an increasingly manipulative fashion. However, he showed no evidence of psychotic thinking or behavior or homicidal or suicidal ideations, and the diagnosis was listed as a "paranoid personality disposition." The report of an August 1987 private psychosocial assessment reveals complaints of depression, inability to sleep and concentrate, and disorganization. The "precipitating stressors" for the veteran's problems reportedly were his abstinence after seven to eight year's use of marijuana, as well as his lack of job stability. The veteran again made reference to his parents' divorce when he was a child and complained of having been abandoned by his mother for her boyfriend and having been put into juvenile detention at age thirteen for "suspicion of drugs." He admitted having experimented with acid and LSD in the seventh and eight grades, and said that he had started smoking marijuana heavily at age 19. He denied a family psychiatric history. On examination, he had a cautious attitude, a blunt affect, a depressed mood, fair motivation and an impaired memory, by self report, but no audio/visual hallucinations. He described himself as a hermit and said that he had been smoking one ounce of marijuana a week for seven years until five months earlier. A bipolar disorder and cannabis abuse, in remission, were diagnosed. According to a May 1991 private medical record, the veteran said that his mother left him when he was 12 years old to live with her boyfriend "like a prostitute" and that, as a result of this, he was sent to juvenile detention, where he was mistreated. His mother signed him into the Navy when he was 17 years old and, after a while, he realized that he had a substance abuse problem. He revealed this to his counselor who reportedly did not keep confidentiality, resulting in a reprimand from his boss, which, in turn, made him want to "beat the system" by using all kinds of drugs. On examination, he had well-organized thought processes, with an emotional and very angry, but appropriate, response, and no history of ideations or psychotic symptoms and no sense of organicity. The assessments were listed as schizophrenia, bipolar disorder and dysthymia, although it appears that these disorders were thereafter ruled out and that a personality disorder was the final assessment, as the subscribing psychiatrist indicated that it was his belief that the veteran was suffering from a personality disorder because of his anger and request for Lithium medication. An August 1991 private medical record reveals assessments of bipolar disorder, dysthymia and a personality disorder. According to the report of a September/October 1993 VA hospitalization, "it was stated that depression ran in the family and that [the veteran]'s father possibly had delusions and hallucinations." On examination, the veteran's speech was fluent, with normal rate and tone, his mood was congruent, "nonconstricted" and labile, and he denied audio or visual hallucinations, delusions or suicidal and homicidal ideations. A drug screen was positive for opiates, specifically codeine. The above report also reveals that an MRI of the veteran's head was normal and that, upon review of the old charts, his diagnosis was not clear, as there was no strong history for bipolar disorder, despite his history of this diagnosis. The veteran underwent both personality and cognitive testing and the specialist's opinion was to the effect that the results of the test suggested a "characterlogic" disturbance rather than a mood disorder such as a bipolar disorder. It was felt that there were no clear indications of frontal lobe dysfunctions or organic explanations for the veteran's problems in functioning, but that further neuropsychiatric evaluation would be warranted. It was the specialist's opinion that the veteran had a passive/aggressive personality disorder. Accordingly, a passive/aggressive personality disorder and bipolar affective disorder, by history, were listed as diagnoses. A May 1994 VA medical record reflects a three-day hospitalization due to a drug overdose. It was noted in this record that the veteran had "a history of post traumatic stress disorder" and depression. He denied suicidal ideations and a psychiatrist reportedly recommended no further psychiatric intervention. A toxicology screen was positive for Benzodiazepines and marijuana. The diagnoses were a psychogenic syncope and a history of depression. A July 1994 VA medical record reflects an eight-day hospitalization during June 1994, following a request from the veteran's psychotherapist, as the veteran reportedly felt "frustrated," like "falling down," and very upset with a recent denial of a claim for Social Security Administration (SSA) benefits. He also reported having had difficulties trusting the medical staff because of his perceived betrayal by the Navy medical personnel when he self-reported his use of marijuana during service, which he said had resulted in his losing his security clearance, a position as an electronic technician and his chances of being a Navy pilot. He further said that he had never recovered from that trauma and that he had never been able to hold a steady job or to have any long term relationships. He denied the use of alcohol or recent drug use. The above report also reveals that, on mental examination, the veteran appeared irritable, and at times, sarcastic, antagonistic and uncooperative. He described his mood as being "pissed off" but had a labile affect. His speech was mildly slurred and angry in tone but was coherent, and there was no evidence of loosening of associations or delusional content, and he denied intention to harm himself or others. He appeared to be manipulative, and had poor insight and impaired judgment. Higher cortical function appeared intact. Urine toxicology screen on the day after admission was positive for cannabinoids, but negative for barbiturates. However, a positive result for barbiturates was obtained five days later, while the veteran was still hospitalized, and it was noted that he had expressed dissatisfaction and anger when requested to comply with the toxicology screen. The diagnosis in Axis I was deferred, while the diagnosis in Axis II was listed as a mixed personality disorder, with borderline narcissistic and passive aggressive traits. At an RO hearing that was conducted in August 1995, the veteran made no reference to any pre-service family problems, family history of psychiatric illness or to his own long history of psychiatric difficulties and drug abuse, of which there is ample documentation in the record. He did say, however, that, during service, he was "singled out for a short time for being more intellectual than those other[s] in [his] company," a form, he and his representative suggested, of "subdued harassment." He declined to elaborate on this allegation, but insisted that he did not have any problems with his duty assignments, nor difficulties with authority figures, but that he was treated for depression and a suicide attempt during service. At the above RO hearing, the veteran also said that his inservice psychiatric problems were the result of his having "been broken illegally," when a counselor to whom he had disclosed his "previous psychological abuse problems with marijuana" breached his obligation of confidentiality and told his commanding officer about his "past" drug history. The veteran's commanding officer then removed him from "all schools" to which he was allegedly admitted, rescinded his security clearance and proceeded to humiliate and degrade him in front of the whole squadron. These actions reportedly left him in a severe state of shock and extremely depressed and suicidal, to the point that he drank approximately one pint of bleach and went back to his room to die, since his commanding officer and others in his squadron had made him feel that this was his "just and fit punishment." The veteran further stated at the above RO hearing that he believed that he should be service-connected for PTSD due to "[t]he fact that I was caused severe shock and emotional trauma by being betrayed by authority figures by being harassed and psychologically conditioned by the authority figures that my life would be in jeopardy." With regard to his PTSD symptoms, he said that he was not able to relate or have any kind of relationships, that he was not sexual or intimate, nor personal, and that he was not social. He also said that he had last worked in 1991, after having had conflicts with his supervisor, and that he believed that his "unfortunate experience" during service had led to his continued problems with authority figures. He also said that he believed that his psychiatric disabilities had been caused by his having been singled out and discriminated against, after admitting "recreational" marijuana use, but acknowledged that the only mention of PTSD in his claims folder was the one noted in the history section of a recent [May 1994] VA hospitalization report. As noted earlier in this decision, the Board denied the veteran's appeal of the RO's August 1995 denial of his claim for service connection for an acquired psychiatric disability, to include PTSD, in a decision that was dated in April 1998, which the veteran appealed to the Court. By Order of July 1999, the Court granted the aforementioned motion to remand, vacating the Board's decision and remanding the matter on appeal, pursuant to the authority granted by 38 U.S.C.A. § 7252(a). In the motion for remand, it was recommended that the Board address, in this opinion, "the applicability of certain provisions set forth in VA's Adjudication Procedure Manual M21-1 ('Manual M21-1'), which seem to require the full development of all claims, whether or not they are well grounded." See, first page of the joint motion for remand. In support of their recommendation that the Board re- adjudicate the matter on appeal, addressing the applicability of the Manual M21-1 provisions requiring the full development of all claims, regardless of whether or not they are well grounded, the subscribers of the joint motion for remand made reference to the case of Carbino v. Gober, 10 Vet. App. 507 (1997). In Carbino, they said, "this Court indicated that issues relating to the development of a not-well-grounded claim under Manual M21-1 should first be raised to and addressed by the Secretary, the Board, and the General Counsel (and may be later reviewed by the Court if necessary)." They further indicated that, in the present matter, "the issue of the applicability and substantive nature of the M21-1 regulations was in fact raised - but not considered by the Board at the time of the decision on appeal." They then recommended the following, in addition to asking the Board to address the applicability of the Manual M21-1 provisions in the first instance, on the third page of their joint motion for remand: If the BVA finds that further development is required, that development should include, at a minimum, appropriate attempts to obtain the following evidence: (1) social security records, (2) service records pertaining to the Appellant's self referral for in-service drug treatment, and the alleged harassment and anxiety he suffered thereafter, in the form of loss of educational, training, and advancement opportunities, and (3) an opinion from a VA psychiatrist on whether Appellant's present psychiatric condition is related to an injury, illness, or incident in service. Legal analysis: As a preliminary matter, the Board notes that, in November 1999, the Board received from the veteran's private attorney before the Court photocopies of an April 1995 decision from the SSA finding the veteran disabled, for SSA purposes, since August 1991, on account of his social and industrial impairment and the diagnosed psychiatric disabilities of a bipolar affective disorder and a borderline personality disorder. Also, photocopies of a three-page psychiatric interview form that was dated in April 1995, as well as a one-page "list of exhibits" document mentioning the evidence that was considered by the SSA in reaching its decision, were enclosed, along with a cover letter from the private attorney, requesting a remand of the matter on appeal, "with instructions [to the RO] to obtain all medical evidence on the LIST," as well as "service records and the required psychiatrist's opinion." A remand to have this evidence reviewed at the RO level is unnecessary because these records would, at most, only serve to support the veteran's contention that he has been suffering from psychiatric difficulties during the '90s, which the Board does not dispute, but it would still not demonstrate that there is a nexus between any present psychiatric disability, or disabilities, and service. Also at the outset, the Board finds it necessary to address the issue of the applicability of the Manual M21-1 provisions to the present matter. In Carbino, the Court did say that the question of whether the Manual M21-1 represents VA's expansion of its statutory duty to assist in cases of claims that are merely "potentially plausible," rather than actually well grounded, is a question that should be first addressed by the Secretary, the Board, and the General Counsel. For that reason, the Court specifically declined to address the applicability of the Manual M21-1 provision in question (Part III, para. 1.103(a)) in that case. The Court, however, made it clear that there is nothing in the text of 38 U.S.C.A. § 5107(a) to suggest that VA has a duty to assist a claimant until the claimant meets his or her burden of establishing a well grounded claim. See, Carbino, at 510, citing Epps v. Gober, 126 F.3d 1464, at 1469 (Fed.Cir. 1997), aff'g, 9 Vet. App. 341 (1996). In fact, the Court explained, while Manual M21-1 appears to volunteer the Secretary's assistance to a claimant with his or her claim prior to the submission of a well grounded claim, "the Epps decision makes clear that the statutory duty to assist does not attach until a well-grounded claim has been submitted." See, Carbino, at 510. In Carbino, the Court also indicated that the relevant parts of Manual M21-1 "do not appear to be particularly well thought out regarding the status of a claimant and the duty to assist," and went on to cite specific provisions of the manual supporting that opinion. See, Carbino, at 510-511. Whatever dispute may have existed after Carbino regarding whether Manual M21-1 requires the full development of a record regardless of whether the claim is well grounded or not, was put to rest in the very recent decision of Morton v. Brown, 12 Vet. App. 477 (1999). In Morton, the Court cited prior cases in which federal courts had explained the difference between substantive rules, which may confer enforceable rights, and mere internal guidelines or interpretive statements, which are mandated neither by a statute nor by the Constitution and which, as such, cannot confer substantive rights on a claimant. See, Morton, at 481-482. The Court explained that "[t]he Supreme Court has consistently held that for an agency's interpretation or action to be entitled to any deference or judicial enforcement, it must be consistent with the framework of the statute. See, Morton, at 484 (cites omitted). The Court then said that the cited Manual M21-1 provision was "purely interpretive" and, thus, could only serve to interpret § 5107(a), and that, to the extent that the Manual M21-1 provision may be read to require the Secretary to assist a claimant who has not submitted a well- grounded claim pursuant to § 5107(a), such a reading would fly against the plain language of the statutory text and exempt courts from any obligation to defer to it. See, Morton, at 485, citing the case of Brown v. Gardner, 513 U.S. 115, 115 S.Ct. 552, 130 L.Ed.2d 462 (1994). In Morton, the Court further explained that § 5107(a) had been interpreted by both the Court and the Federal Circuit as conditioning the Secretary's duty to assist in developing the facts pertinent to the claim upon the submission by the claimant of a well grounded claim, and then the Court went on to underline the fact that "neither the Secretary nor the Court is free to ignore a condition precedent established by Congress," and explained that if a change were to be instituted, that balancing process would be "the [sole] responsibility of the legislative branch, not this Court." The Court then concluded that, under § 5107(a), absent the submission and establishment of a well-grounded claim, the Secretary cannot undertake to assist a veteran in developing facts pertinent to his or her claim and that, accordingly, any perceived or actual failure by the Secretary to render assistance in the absence of a well-grounded claim cannot be legal error. See, Morton, at 485-486. From the above discussion, it is clear that, pursuant to the provisions of the applicable statute (§ 5107(a)), the provisions of the Manual M21-1 notwithstanding, the Board first needs to determine, in the present case, if the veteran has complied with his initial duty to submit a claim for service connection that is well-grounded or capable of substantiation and, if it is determined that he has done so, then, and only then, would the Board have the duty to further assist the veteran in the development of his claim for service connection. It is clear that the veteran has failed to submit a claim for service connection for an acquired psychiatric disorder, to include PTSD, that is plausible, or well grounded, as he has failed to objectively demonstrate that any current psychiatric disability is causally related to service. The "immature personality" that was diagnosed during service in March 1975 is clearly a personality disorder and, as such, a disease entity that is not considered a disability for VA purposes (as per the provisions of §§ 3.303(c) and 4.9), while the depressive reaction that was diagnosed on that same date was evidently not a chronic condition, as it was noted to be "secondary to [an] acute situational adjustment." The record is devoid of competent evidence showing that any psychiatric disability had its onset, or was aggravated, during service, as it has been made very clear in the veteran's service and post-service medical records, that the veteran entered service with a long history of depression, reportedly triggered by his serious problems at home, and aggravated by his well-known history of drug abuse, which not only is considered willful misconduct, but has been shown to have started before service. With regard to the specific claim for service connection for PTSD, the Board notes that there is no clear, unequivocal diagnosis of such a disability in the claims file, nor competent evidence of the actual occurrence of an inservice stressor, or stressors, which is a criterion with which the claimant in the present matter has to comply, too, since he has not been shown to be a combat veteran. Also, the record is devoid of competent evidence linking the claimed, but undiagnosed PTSD, to service. No further development of the PTSD issue is therefore warranted. With regard to the nexus criterion, the Board further notes that, not only is the record devoid of competent medical evidence demonstrating that the claimed nexus, or causal relationship, between service and a present psychiatric disability exists, but the only evidence in that regard consists of the veteran's own unsubstantiated statements, which are considered lay evidence and, as such, are insufficient to render his claim well grounded. In this regard, it is noted that the Court has indicated that where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A claimant would not meet his or her burden of presenting a plausible or possible claim merely by offering lay testimony because lay persons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Consequently, lay assertions of medical causation cannot constitute evidence to render a claim well-grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well- grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In view of the above, the Board must necessarily conclude that the veteran has failed to submit a claim for service connection for a psychiatric disability, to include PTSD, that is well grounded or capable of substantiation. The claim for that benefit has failed and must be denied. Where a claim is not well grounded, it is incomplete, and VA is obliged under the provisions of 38 U.S.C.A. § 5103(a) (West 1991) to advise the claimant of the evidence needed to complete his or her application. Robinette v. Brown, 8 Vet. App. 69 (1995). The nature and extent of this obligation, however, depends on the particular circumstances of each case. Beausoleil v. Brown, 8 Vet. App. 459, 465 (1996). There must exist "some degree of probability" that the claimant will be able to obtain the additional information needed in order for that obligation to arise. Marciniak v. Brown, 10 Vet. App. 198, 202 (1997). No such obligation arises "in circumstances where the performance of that duty would be a futile act." Franzen v. Brown, 9 Vet. App. 235, 238 (1996). With regard to the above provision, it is noted that the Board has thoroughly reviewed the record but has determined that advising the veteran of additional evidence that might be needed to complete his application for service connection would constitute a futile act in the present case, as the record is crystal clear in that any psychiatric disability currently manifested is not causally related to service but, instead, of pre-service onset and either of a congenital nature, and/or due to, or aggravated by, the veteran's own willful misconduct. The matter on appeal remains not well grounded or capable of substantiation and, accordingly, the cited obligation under § 5103(a) to further assist the veteran has not arisen. ORDER Service connection for a psychiatric disability, to include PTSD, is denied. MICHAEL S. SIEGEL Acting Member, Board of Veterans' Appeals