Citation Nr: 0514204 Decision Date: 05/24/05 Archive Date: 06/01/05 DOCKET NO. 96-00 959 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD R. A. Seaman, Counsel INTRODUCTION The appellant is a veteran who served on active duty from February 1972 to September 1974. This case is before the Board of Veterans' Appeals (Board) on May 2003 remand from the United States Court of Appeals for Veterans Claims (Court) pursuant to a joint motion by the parties (Joint Motion). The appeal was initiated from a February 1995 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. (The claims folder was subsequently transferred to the Huntington RO). In August 1996, the veteran appeared for a personal hearing before a hearing officer at the RO. In February 1997 he appeared before the undersigned at a Travel Board hearing at the Newark RO, and in April 2002 he appeared before the undersigned at a hearing in Washington D.C. The case was before the Board in May 2002, when the Board denied service connection for PTSD. The veteran appealed that decision to the Court, and by a May 2003 Order, the Court vacated the May 2002 Board decision and remanded the matter for readjudication. Pursuant to the Court's Order, the Board remanded the case to the RO in November 2003 for readjudication consistent with the Joint Motion. The case is now back before the Board for further appellate review. FINDINGS OF FACT 1. The veteran did not engage in combat. 2. There is no credible supporting evidence that the veteran was subjected to a stressor event in service, and he has provided no meaningful information which can be used as the basis for another attempt to confirm his alleged stressor(s) in service. 3. The preponderance of the competent evidence is against a finding that the veteran has PTSD that is related to service. CONCLUSION OF LAW Service connection for PTSD is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304(f) (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSION On November 9, 2000, the Veterans Claims Assistance Act of 2000 (VCAA), (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107) became law. Regulations implementing the VCAA are at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). The VCAA and implementing regulations apply in the instant case, and the requirements therein appear met. Well-groundedness is not an issue. The veteran was provided VCAA notice by March and July 2004 correspondence from the RO, and in a supplemental statement of the case (SSOC) issued in February 2005. Although he was provided VCAA notice subsequent to the February 1995 RO decision appealed (incidentally, notice would not have been possible prior to enactment of the VCAA), he is not prejudiced by an notice timing defect. He was notified (in the February 1995 decision, in a statement of the case issued in July 1995, and in numerous SSOCs issued throughout the course of this appeal) of everything required, and has had ample opportunity to respond or supplement the record. The case was reviewed de novo subsequent to the notices. Regarding content of notice, the SOC and SSOCs informed the veteran of what the evidence showed. March and July 2004 correspondence and the February 2005 SSOC informed him of the controlling law and regulations. He was advised in the correspondence, and in the February 2005 SSOC, that VA would make reasonable efforts to help him get pertinent evidence, but that he was responsible for providing sufficient information to VA to identify the custodian of any records. The correspondence and the February 2005 SSOC advised him of what the evidence must show to establish entitlement to service connection for PTSD, and what information or evidence VA needed from him. Specifically, the March and July 2004 correspondence, and the February 2005 SSOC, informed him of the allocation of responsibility of the parties to identify and obtain additional evidence to substantiate the claim. While the veteran was not advised verbatim to submit everything he has pertaining to his claim, he was advised to submit, or provide releases for VA to obtain, any pertinent records. The July 2004 correspondence specifically advised the veteran to let VA know "[i]f there is any other evidence of information that you think will support your claim." This was equivalent to advising him to submit everything pertinent. Everything submitted to date has been accepted for the record and considered. Regarding the duty to assist, VA has obtained all records of which there was notice. Although a great deal of medical evidence has been generated during the pendency of this appeal, the Board has considered whether additional VA examination or advisory opinion is necessary. A medical opinion or an examination is necessary: (summarized) If the record is insufficient to decide the claim, but contains evidence of a current diagnosis of the disability; establishes an event, injury or disease in service; and indicates the current diagnosed disability may be related to the disease, injury, event in service. 38 C.F.R. § 3.159. Here, there is no evidence of an event in service, and no competent evidence that any currently diagnosed PTSD may be related to a verified event in service. Consequently, an examination or a medical opinion is not indicated. As noted, the claim was reviewed de novo (see February 2005 SSOC). Development is complete to the extent possible; VA's duties to notify and assist are met. Hence, the Board finds it proper to proceed with appellate review. It is not prejudicial to the veteran for the Board to do so. Mayfield v. Nicholson, No. 02-1077 (U.S. Vet. App. April 14, 2005); Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Background Essentially, the veteran contends that service connection for PTSD is warranted due to stressors he experienced during service, including being beaten and sexually assaulted during his incarceration at Fort Leavenworth, Kansas; witnessing physical assaults on other inmates; and the general stress of being incarcerated. Service medical and personnel records are negative for treatment or diagnosis of any psychiatric symptoms, including PTSD or PTSD-related symptoms. Medical records associated with the veteran's incarceration in Fort Leavenworth are also part of his service medical records. The records include an admission summary by a social worker in March 1973, during the veteran's incarceration. He had been confined at Fort Leavenworth for several months prior to the admission summary, and the summary is devoid of any complaints of, or reference to, a physical/sexual assault during his incarceration. In October 1974, the veteran filed a claim seeking service connection for a nervous condition that began in 1972. His application for compensation includes no reference to a sexual assault in service. Postservice evidence includes medical records showing that the veteran was hospitalized in a VA medical facility from October 1974 to February 1975. He was treated for drug abuse (heroin and amphetamines) and other health problems. The records are negative for diagnosis of a psychiatric condition, and the veteran made no complaints of being physically or sexually abused in service. The veteran underwent a VA psychiatric evaluation in April 1975, during which he had no complaints of a sexual assault during service. Examination revealed no indication of psychotic symptomatology in the sense of delusion, hallucination, or ideas of reference. The examiner reported that there was neurotic symptomatology "perhaps the residual of withdrawal from drugs." From the history provided by the veteran, the examiner diagnosed unclassified neurosis, residual of drug use and alcoholism. Of record is a December 1975 administrative determination whereby it was determined that the veteran's character of discharge for his service from February 1972 to September 1974 was to be considered by VA as under conditions other than dishonorable. In a February 1976 rating decision, the RO denied service connection for a nervous condition. The RO did not specifically address the matter of service connection for PTSD. Additional VA outpatient treatment records dated from May 1975 to January 1978 do not show specific diagnosis of PTSD. Several clinical reports in that period show diagnosis of drug abuse, and none contain any reference to a physical or sexual assault in service. A January 1976 outpatient record shows that the veteran complained of a "nervous condition," and a notation in the record indicates that he had been using heroin since he was 13 years old. The diagnosis was thought disorder. A September 1976 clinical record indicates that the veteran was attending a drug rehabilitation program, and was seeking a prescription of Valium. A March 1977 VA medical certificate indicates that the veteran's primary complaint was that he "can't relax his mind." It was noted that he was a heroin addict, for which Valium had been prescribed in the past with good relief. The diagnoses were heroin addict and anxiety. Valium was prescribed, and the veteran was advised of the "risk of abuse of Valium in known drug abuser." The veteran filed a claim seeking service connection for PTSD in October 1994. A VA discharge summary of inpatient care shows that he was hospitalized from September to October 1994 "to help him address issues relating to his long-term dysfunctional life-style." The hospital summary shows diagnoses chronic PTSD, delayed; depression; alcohol dependence, in remission; opiate dependence; and antisocial personality disorder. In December 1994 correspondence, the veteran reported that during his incarceration in Fort Leavenworth, he witnessed the beating and stabbing of another prisoner who had apparently refused sexual advances of fellow inmates. He stated that he reported the incident, and was given Valium (apparently by prison medical personnel) and placed on a different prison tier. He also reported that in July 1973 he was the victim of an attempted rape by a prisoner who had previously threatened him "with his life 3 times." The veteran stated that the attempted rape was thwarted by three other prisoners who intervened on his behalf. He later "joined in with them, but was forced to commit sexual molestation on [another] inmate . . . for fear that if I didn't they would do me." The veteran stated that he has been afraid ever since the attempted rape, and he complained of nightmares. On December 1994 VA psychiatric evaluation, the veteran informed the examiner that he had been charged with insubordination and unauthorized leave during service, for which he was sentenced to six months of hard labor at Fort Leavenworth. He reported that he witnessed and experienced brutality and violence while he was in prison. He recalled that he saw other prisoners attacked with knives on three occasions, and another prisoner was burned with lighter fluid. He also reported that, on three occasions, another inmate beat him and threatened his life after he refused to submit to his sexual advances. The veteran denied any use of alcohol or drugs prior to service. His subjective complaints were noted and objective evaluation was performed. The diagnoses were depressive disorder with psychotic features, and a borderline personality disorder. The examiner opined that the "specific criteria necessary for diagnosis of [PTSD] are not met in this case." At the August 1996 hearing before the hearing officer at the RO, the veteran testified that he was physically as well as sexually abused while incarcerated at Fort Leavenworth. He reiterated his contentions regarding an attempted sexual assault on him during his incarceration, and that three other inmates had intervened and stopped the assault. He also testified that during the incarceration he was seen by a psychiatrist on different occasions who gave him Valium. At the February 1997 hearing before the undersigned, he again essentially reiterated previous contentions. His representative conceded that the service medical records do not reflect any treatment for a condition indicative of physical beatings and/or sexual assaults. In support of his claim, the veteran submitted a statement from his spouse, who indicated that she had known the veteran since 8th grade, and it was not until 20 years after his service that the veteran told her about being physically and sexually assaulted during his incarceration at Fort Leavenworth. In a January 1997 letter, a VA psychologist stated that the veteran had successfully completed a VA evaluation and treatment program for Vietnam veterans, and that the veteran's status was unique in that "his stressors were not combat related but rather occurred while in military prisons." The psychologist reported that the veteran exhibited all the "classic symptoms" of PTSD; the service records are "sketchy" regarding the treatment the veteran experienced while incarcerated; and the veteran's accounts of events at Fort Leavenworth were very similar to other veterans whom the psychologist had treated. In a February 1997 memorandum, a chief of a VA mental hygiene clinic reported that the veteran had been treated at the clinic for approximately three years, and he carried a diagnosis of PTSD with recurrent episodes of depression. The Board remanded this case to the RO for additional development in April 1997. Pursuant to the remand directives, the RO contacted the veteran in September 1998, and asked him to provide any additional medical records that might reflect the psychiatric treatment he allegedly was provided while he was confined at Fort Leavenworth. Additional efforts to obtain records in support of the veteran's claim also were initiated by the RO. In October 1998, the National Personnel Records Center (NPRC) responded to the RO's request for additional service records by reporting that all medical records had already been submitted. In December 1998, the RO contacted the U.S. Army Crime Records Center, and in a December 1998 response it was indicated that the veteran was incarcerated for wrongful possession of a hypodermic instrument with intent to use, wrongful use of a controlled substance, carrying a concealed weapon, housebreaking, larceny, and forgery. It was also reported that a search of Army criminal file indexes indicated no additional information regarding the veteran. In 1998 and 1999, the RO made extensive efforts to obtain additional records from the Fort Leavenworth. Numerous requests for information were submitted. Additional outpatient treatment records were obtained, including a medical record indicating the veteran was hospitalized from March to July 1995. The hospitalization report indicates diagnoses and treatment for PTSD, depression, alcohol dependence, and opioid dependence (in remission). The records contain only negligible reference to any alleged stressor, and are devoid of any specific reference to an alleged sexual assault in service. There was reference to "the unique nature of his military experience," and it was noted that the veteran "worked hard on 2 specific events in particular . . . ." In a June 1999 response to the RO's request for information, the Commandant of the United States Disciplinary Barracks at Fort Leavenworth stated that following the veteran's release from prison, his records were retired to the NPRC, where they were maintained for 25 years and then destroyed. The Commandant reported that correctional records are no longer available for someone confined in 1973. With regard to the RO's request for information regarding three witnesses (fellow inmates) who came to the veteran's aid during the alleged assault (their names were provided to Fort Leavenworth authorities in a May 1999 letter from the RO), the Commandant indicated that he had no information available on those individuals. A February 2000 report of psychiatric consultation indicates diagnosis and treatment for PTSD as a result of the veteran's experiences in Fort Leavenworth. The veteran reported that while he was in prison, he was assaulted, held down, and another inmate attempted to rape him. He indicated he was knocked unconscious, and that someone intervened just before he was penetrated. The diagnoses were PTSD and personality disorder, not otherwise specified with anti-social and paranoid features. In December 2001 correspondence, the veteran asserted that had the RO acted more promptly, records from Fort Leavenworth could have been obtained within 25 years of the veteran's incarceration. In this regard, the Board notes that it has reviewed the veteran's service medical records, and there is no indication (other than the veteran's own contentions) that the service medical records are incomplete. As noted above, the NPRC has notified the RO that all service records have been submitted. At the April 2002 hearing before the undersigned, it was reaffirmed that the veteran did not serve in Vietnam and had no combat service. He indicated that he was receiving Social Security disability benefits based solely on the diagnosis of PTSD, and in April 2002 VA received information from the veteran regarding such benefits. The Social Security determination expressly indicates that the veteran was found disabled (for purposes of entitlement to Social Security benefits) due to "anxiety disorders and personality disorders." A diagnosis of PTSD is neither shown nor referenced in the Social Security determination. At the hearing, the veteran was informed that the RO had attempted to contact the three witnesses he identified at the prior Travel Board hearing, and he was advised that attempts to contact those individuals had failed. When the veteran was asked whether he had heard from these people or contacted them, he responded that it was against the law for him to contact any of these people, and as inmates they were not "that kind of friends." The veteran indicated there were no additional records pertinent to his claim that the Board or the RO could obtain. He requested a 30-day extension to obtain additional records, which was granted, and other than the above-cited information regarding his Social Security determination, no additional records were submitted. Additional VA outpatient records were obtained, dated through February 2005, showing treatment the veteran received for a variety of medical problems. The records are negative for any reference to the veteran's service or his alleged stressors. A February 2002 outpatient report indicates that the veteran complained mainly of "anxiety related to various stresses he was having." The report shows diagnoses of PTSD, personality disorder, and psychotic disorder. A July 2003 clinic record shows that the veteran consulted with a VA social worker to discuss his continued participation in a private methadone maintenance program. Legal Criteria and Analysis Service connection may be granted for disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for a 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). Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). 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 in-service stressor. 38 C.F.R. § 3.304(f); West v. Brown, 7 Vet. App. 70 (1994). Where the veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, then the veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997). Service department records must support, and not contradict, the claimant's testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). Here, the record before the Board demonstrates clearly that PTSD has been diagnosed. Notwithstanding, as stated by the Court, "[j]ust because a physician or other health professional accepted the appellant's description of his active service experiences as credible and diagnosed the appellant as suffering from PTSD does not mean the [Board is] required to grant service connection for post-traumatic stress disorder." Wilson v. Derwinski, 2 Vet. App. 614 (1992). The Board is not required to accept a veteran's uncorroborated account of his active service experiences. See Wood v. Derwinski, 1 Vet. App. 190 (1991). It is also clear that the Board is not required to accept a veteran's statements regarding his alleged symptoms, including nightmares, flashbacks, and other difficulties he associates with his active service, if the Board does not find the statements regarding his symptoms to be credible. The starting point for analyzing a claim of service connection for PTSD is a determination whether there is evidence of one or more "stressors." The question of a "stressor" also bears upon credibility determinations, as certain veterans who "engaged in combat with the enemy" gain evidentiary presumptions. 38 C.F.R. § 3.304(d). Under the controlling regulation, there must be credible supporting evidence that the claimed service stressor actually occurred. 38 C.F.R. § 3.304(f). The existence of an event alleged as a "stressor" that results in PTSD, though not the adequacy of the alleged event to cause PTSD, is an adjudicative, not a medical determination. Zarycki v. Brown, 6 Vet. App. 91 (1993). Under the framework established in Zarycki, the Board must make an explicit determination as to whether the veteran engaged in combat with the enemy. In this case, the veteran has conceded that he did not engage in combat with the enemy. Accordingly, the Board has determined that the veteran did not engage in combat with the enemy as defined within 38 U.S.C.A. § 1154(b). As a result, as a matter of law, a medical care provider cannot provide supporting evidence that the claimed in-service event actually occurred based on a post-service medical examination. See Moreau v. Brown, 9 Vet. App. 389 (1996). In addition, the veteran's own testimony will not be sufficient. Id. Other credible supporting evidence from any source must be provided. The veteran's alleged stressors in service include the following: (1) witnessing attacks on fellow inmates by other inmates during his incarceration; (2) the general stress involved in being incarcerated; and (3) the alleged sexual assault. In evaluating these alleged stressors, the Board must note that all of them occurred while the veteran was incarcerated in Fort Leavenworth. As a result, the Board has considered the issue of whether or not such alleged injuries can be considered to have occurred in the line of duty. The provisions of 38 C.F.R. § 3.1(m) mandate that the requirements as to line of duty are not met if, at the time that the injury was suffered or disease contracted, the veteran was either: (1) avoiding duty by desertion, or absent without leave which materially interfered with the performance of military duty; (2) confined under a sentence of court-martial involving an unremitted dishonorable discharge; or (3) confined under sentence of a civil court for a felony as determined under the laws of the jurisdiction where the person was convicted by such court. See also 38 U.S.C.A. § 105 (West 2002). The language of § 3.1(m), by qualifying the type of confinement under a sentence of a court-martial to that which involved an "unremitted dishonorable discharge" strongly implies that confinement as a result of any other reason, such as pretrial confinement or by reason of a court-martial sentence other than one that included an unremitted dishonorable discharge (as in this case), does not prohibit a favorable line-of-duty determination for an injury or disease contracted during the confinement. This is significant in this case because the available records do not show at this time that the veteran received a sentence that included a dishonorable discharge. The December 1975 VA administrative decision determined that the veteran should be discharged under conditions other than dishonorable. Therefore, the Board has determined that any verified trauma experienced by the veteran in service would be considered as incurred in the line of duty. This does not, however, end the analysis in this case. Upon reviewing the evidence, the Board finds that the veteran has failed to supply "credible" evidence of his alleged inservice stressors. None of his alleged stressors in service is confirmed, and the Board finds no basis by which VA could confirm such stressors. The special provisions of VA Adjudication Procedure Manual M21-1 (M21-1), Part III, regarding personal assault have been considered in reaching this determination. M21-1 notes that: "Personal assault is an event of human design that threatens or inflicts harm. Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking." M21-1, Part III, 5.14c. M21-1 identifies alternative sources for developing evidence of personal assault, including private medical records, civilian police reports, reports from crisis intervention centers, testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, and personal diaries or journals. M21-1, Part III, 5.14c(4)(a). When there is no indication in the military record that a personal assault occurred, alternative evidence, such as behavior changes that occurred at the time of the incident, might still establish that an in-service stressor incident occurred. Examples of behavior changes that might indicate a stressor include: visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; sudden requests that the veteran's military occupational series or duty assignment be changed without other justification; lay statements indicating increased use or abuse of leave without apparent reason; changes in performance or performance evaluations; lay statements describing episodes of depression, panic attacks or anxiety with no identifiable reasons for the episodes; increased or decreased use of prescription medication; evidence of substance abuse; obsessive behavior such as overeating or undereating; pregnancy tests around the time of the incident (obviously not at issue in this case); increased interest in tests for HIV or sexually transmitted diseases; unexplained economic or social behavior changes; treatment for physical injuries around the time of the claimed trauma but not reported as a result of the trauma; breakup of a primary relationship. M21-1, Part III, 5.14c(7)(a)-(o). After extensive and careful review of the evidence of record, the Board concludes that there is no credible documented evidence to indicate that the veteran experienced any of the identified behavior changes, or any other unusual behaviors during his active military service. Particularly damaging to his case are medical records dated immediately following his separation from service; medical records which are entirely negative for any reference to the alleged stressors. While there is documentation of drug abuse (one of the above-listed indicators of behavior changes which might evidence an in- service stressor) almost immediately after service, this was not a new behavior. The veteran's incarceration in service was, in part, for possession of drugs/drug paraphernalia, and postservice medical evidence indicates drug use dating back to when he was 13 years old. The Board has noted the extensive efforts of the RO to confirm the veteran's alleged stressors; efforts that have yielded no results. The Board has reviewed the service medical records and they appear complete. There is absolutely no indication that the veteran underwent treatment for assault or for a psychiatric condition during his incarceration in Fort Leavenworth (as contended). Specifically, medical records from Fort Leavenworth among the veteran's service medical records fail to reveal any indication of PTSD or PTSD-related symptoms. Medical records generated immediately following his separation from service only support this finding. These facts do not support the claim. The Board is aware of the Court's decision in Patton v. West, 12 Vet. App. 272 (1999). Patton involved an allegation of noncombat personal assault as the alleged stressor with respect to PTSD. The Court noted that certain provisions in VA Manual M21-1 apply to such claims. In this case, however, the Board has specifically determined that every effort to confirm the veteran's alleged stressor in service has been undertaken, with negative results. Furthermore, it is noteworthy that extensive medical evidence and other evidentiary records fail to support the veteran's alleged stressors in service. Specifically, medical records following the veteran's separation from service provide no indication of an alleged sexual assault. The records indicate that he did not report the alleged sexual assault to any individual in whom he confided until decades after his discharge from active service. His own testimony before the undersigned was not entirely consistent with statements he initially made to the VA regarding his psychiatric disability following service, and these facts weigh against his claim. VA psychiatric evaluation in December 1994 found that the criteria necessary for a diagnosis of PTSD were not met. Although PTSD has been diagnosed on other occasions, such diagnoses were based on stressor events that are not confirmed. Consequently, there is no need to resolve the inconsistency in the medical evidence as to whether the psychiatric symptoms shown support a diagnosis of PTSD. To establish entitlement to service connection for PTSD, the veteran must present both medical evidence diagnosing the condition and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Without credible supporting evidence of an in-service stressor, even unequivocal medical evidence that a claimant has all the symptoms needed to establish that he has PTSD would be insufficient to establish service connection for the PTSD, i.e., establish that the PTSD is service related. The veteran's own statements and contentions (and those of his spouse), regarding a relationship between his current psychiatric symptoms and in-service traumatic events cannot by themselves establish the nexus between his current psychiatric problems and his military service. They are laypersons and, as such, are not competent to provide probative evidence as to matters requiring expertise regarding specialized medical knowledge, skill, training, or education (such as medical nexus). See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The preponderance of the evidence is against the claim for service connection for PTSD. Although the veteran is entitled to the benefit of the doubt when the evidence supporting his claim and the evidence against the claim are in equipoise, the benefit of the doubt doctrine does not where, as here, the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for PTSD is denied. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs