Citation Nr: 1234978 Decision Date: 10/09/12 Archive Date: 10/17/12 DOCKET NO. 03-15 287A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a left knee disability. (The issue of whether a request for a waiver of recovery of a loan guaranty indebtedness in the calculated amount of $25,354.90, plus interest, was timely filed, is the subject of a separate decision.) REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Barner, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1970 to November 1973 and September 1980 to August 1991. This matter came to the Board of Veterans' Appeals (Board) on appeal from an October 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In May 2009, the Veteran testified at a Board hearing at the RO. A copy is associated with the record. This appeal was previously before the Board in December 2009, at which time it was remanded to obtain stressor verification, and VA examinations regarding PTSD and the left knee. In March 2010 the Defense Personnel Records Information System responses regarding claimed stressors were received. The Veteran was afforded VA examinations, to include for PTSD in July 2011, and for his left knee in April 2010. Given the foregoing, the Board finds that VA has substantially complied with the Board's prior remand with regard to this appeal. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with Board's remand instructions). In August 2011, subsequent to the RO's most recent July 2011 supplemental statement of the case the Veteran submitted a letter in which he disagreed with the VA psychiatric examiner's findings. Although the Board may not typically consider newly received evidence in the first instance, in light of the Board's grant of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, there is no prejudice to the Veteran in continuing with the appeal. The issue of whether a request for a waiver of recovery of a loan guaranty indebtedness in the amount of $25,354.90, plus interest, was timely filed, is the subject of a separate decision. See BVA Directive 8430, Board of Veterans' Appeals, Decision Preparation and Processing, 14(c)(10)(a)(1) (providing that because they differ from other issues so greatly, separate decisions shall be issued in loan guaranty cases in order to produce more understandable decision documents). The issue of entitlement to a total disability rating based on service connected disabilities has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's claimed in-service stressor of fearing for his life after a nearby bombing in Frankfurt, Germany, is satisfactorily established. 2. The Veteran's response to the claimed stressor event involved a psychological or psycho-physiological state of fear, helplessness, or horror. 3. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's claimed in-service stressor of personal assault involving being chased by a mob is satisfactorily established by the record. 4. The Veteran is currently diagnosed as having PTSD, and his symptomatology has been attributed to his claimed in-service stressors by a VA psychologist. 5. A left knee disability did not manifest in service, within the one year presumptive period or for many years thereafter, and is not otherwise related to service. CONCLUSIONS OF LAW 1. Giving the benefit of the doubt to the Veteran, an acquired psychiatric disorder, to include PTSD, was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2011). 2. Left knee disability was not incurred in service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With respect to the Veteran's claim regarding entitlement to service connection for an acquired psychiatric disorder, to include PTSD, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2011). To the extent there may be any deficiency of notice or assistance, there is no prejudice to the appellant in proceeding given the favorable nature of the Board's decision. The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2011). For the reasons to be discussed below, the Board finds that VA has satisfied its duties to the appellant under the VCAA. A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). With respect to the claim of entitlement to service connection for a left knee disability, VA has made all reasonable efforts to assist the Veteran in the development of his claim, has notified him of the information and evidence necessary to substantiate the claim, and has fully disclosed VA's duties to assist him. In May 2004, the Veteran was notified of the information and evidence needed to substantiate and complete the claim on appeal. Additionally, a March 2006 letter provided him with the general criteria for the assignment of an effective date and initial rating. Id. The Board notes that, in the present case, complete notice was not issued prior to the October 2004 adverse determination on appeal. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Nevertheless, VA rectified any timing error in providing notice to the Veteran and subsequently readjudicating his claim on several occasions, most recently in July 2011. Id.; see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). The Board further finds that VA has complied with the duty to assist by aiding the appellant in obtaining evidence. It appears that all known and available records relevant to the issue on appeal have been obtained and are associated with the Veteran's claims files. The Veteran's service treatment records, as well as VA and non-VA medical records have been obtained. He has also been afforded VA medical examinations for his knee on several occasions, most recently in April 2010. The Board notes that the VA examination report contains sufficiently specific clinical findings and informed discussion of the pertinent history and clinical features of the disability on appeal and is adequate for purposes of this appeal. In May 2009, the Veteran was afforded the opportunity to testify before the Board. Moreover, during the Board hearing and in discussion off the record, the undersigned asked questions designed to elicit relevant information regarding the Veteran's symptoms. The Board Member clarified the issue on appeal, confirmed that there was no outstanding evidence, and explored alternative bases for claimed entitlement. This action provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments with regard to the claim for service connection, supplementing VCAA notice and in compliance with 38 C.F.R. § 3.103(c)(2) (2011). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board is not aware, and the Veteran has not suggested the existence of, any additional pertinent evidence not yet received. Based on the foregoing, the Board finds that the Veteran has not been prejudiced by any failure of VA in its duties to notify and assist him, and that any such violations could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Thus, adjudication of his claim at this time is warranted. Applicable Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp 2011); 38 C.F.R. §§ 3.303, 3.304 (2011). Service connection may 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 or aggravated by service. 38 C.F.R. § 3.303(d) (2011). Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Effective July 13, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. The amendment to 38 C.F.R. § 3.304(f) adds the following: If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3)(2011), as added in 75 Fed. Reg. 39,843-852 (July 13, 2010). The amendment to the regulation was made effective, in pertinent part, for all claims appealed to the Board before July 13, 2010, which had not been decided by the Board as of July 13, 2010. Cases involving allegation of a personal assault fall within the category of situations in which it is not unusual for there to be an absence of service records documenting the events of which the Veteran complains. See, e.g., Patton v. West, 12 Vet. App. 272, 281 (1999). As noted under Paragraph 5.14(d), Part III, of VA's Adjudication Procedure Manual, M21-1, 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. Service records may not contain evidence of personal assault, and alternative sources, including testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, may provide credible evidence of an in-service stressor premised on personal assault. See YR v. West, 11 Vet. App. 393, 399 (1998). The Manual also notes that because personal assault, to include sexual assault, can be an extremely personal and sensitive issue, many incidents of personal assault are not officially reported, making it difficult to obtain direct evidence, and requiring that alternative evidence be sought. Id. Under 38 C.F.R. § 3.304(f)(3), if a PTSD claim is based on an in-service personal assault, evidence 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; pregnancy tests or tests for sexually transmitted disease, 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 these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to a request for a 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 behavior changes. 38 C.F.R. § 3.304(f)(3) (2011). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may legitimately be questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2011). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. Applicable Facts PTSD In this case, the Veteran seeks service connection for PTSD, claiming that he developed PTSD as a result of service. Specifically, he contends that while stationed in Germany between March and May of 1972, he was attacked by an anti-American mob. He also reports that on May 11, 1972, the Bader Meinoff gang exploded a bomb in the 5th Army Headquarters which killed a colonel and a few other officers. The Veteran indicated that he was in a building across the street when the explosion occurred. The Veteran is not in receipt of any military citations indicative of combat service, and he has not contended that he engaged in combat. As such, the combat presumption under 38 U.S.C.A. § 1154(b) does not apply, and service connection will be considered under the amended regulatory provision, 38 C.F.R. § 3.304(f)(3). In evaluating the Veteran's claim under the amended regulatory provision, the Board will first consider whether the Veteran's claimed stressor event is consistent with the places, types, and circumstances of his service. The Veteran's DD Form 214 and personnel records show that he was on assignment to the 18th Financial Section, and served in Germany from March 1972 to November 1973. Service enlistment examination in November 1970 indicated that he was psychiatrically normal. The Board previously found that there was medical evidence of record showing that the appellant has been diagnosed as having PTSD as a result of these incidents, and remanded in order to develop corroborative evidence of claimed noncombat stressors. As discussed above, the regulations have since been liberalized to allow lay statements alone to establish claimed stressors under certain circumstances. VA treatment records from 2001 and 2002 show that the Veteran reported many years of awakening from reoccurring nightmares of someone chasing after him. He endorsed isolative behavior and hypervigilance. He was at that time diagnosed with a mood disorder secondary to alcohol dependence, and notes indicated that he was to be scheduled for a mood intake review in the future given uncertainty of PTSD diagnosis in the context of alcohol dependence. He completed an Alcohol and Drug Treatment Program. An October 2003 letter from Jeffrey Matloff, Ph.D., indicated that the Veteran reported experiencing PTSD symptomatology stemming from his experiences in Germany while stationed in Frankfurt with the 18th Finance Section. The Veteran reported that he was exposed to racial discrimination, to include being physically chased and attacked by a mob of anti-American protestors who used racial epithets, and pushed and shoved him, although he ultimately outran the mob and found transportation back to base. The Veteran also reported that in 1972 he was down the street when he heard the 5th corps headquarters explosion, which was caused by a planted bomb and killed Americans. The Veteran also reported being in a car that was caught by a mob that rocked the car and beat the windows, such that he and the other soldiers in the car escaped by running a red light. Dr. Matloff indicated that the Veteran experienced daily intrusive recollections of being overwhelmed by the mob in Germany. Although he used to experience nightmares at least once weekly, he reported that his current medication helped decrease the frequency. The Veteran, however, continued to suffer from a significant sleep disorder in which he awoke every 2 hours nightly. The Veteran was isolative and avoidant, and tended to stay home most of the time. He reported that he was hypervigilant and engaged in perimeter checking when he awoke at night. The Veteran reported that he had been kicked out of the Army in 1992 following drug rehabilitation failure, since which he had 5 to 6 jobs, the longest of which lasted 6 months, and that he last worked in 1994. The Board observes that his DD Form 214 shows honorable service. Assessment was of PTSD and depression not otherwise specified, and cocaine dependence in full sustained remission. He was assessed as having a GAF score of 39. In January 2004 the Veteran contended that he was entitled to service connection for PTSD. VA treatment records from 2004 to 2006 showed that the Veteran was treated for PTSD, including anger management. In January 2005 he wrote discussing the anti-American sentiment n Frankfurt during the Vietnam War, and his fear for his life when he happened into an anti-American mob that recognized him as an American. Later that week he indicated that 5th headquarters were bombed. In a November 2006 RO hearing the Veteran explained that while in Frankfurt, Germany, he had been attacked by an anti-American mob, although he was able to get away, and later in May 1972 he was with the 18th Finance Section across the street from 5th Army headquarters that were bombed. He indicated that he was not armed at the time that the bombing occurred. The Veteran submitted numerous articles from Time and other websites discussing the bombing of the U.S. 5th Army Corps headquarters in Frankfurt during 1972 by Meinhoff and Baader. Another article discussed the history of the Red Army Fraction, including the May 1972 bombings. VA treatment notes from 2007 show that the Veteran received individual therapy. The Veteran's assessment included PTSD, major depressive disorder, in remission, alcohol dependence, in remission, cocaine dependence, in full sustained remission, and nicotine dependence, current. Testing showed that the Veteran scored highest on intrusive recollections, physiological arousal, loss of interest, detachment, foreshortened future, sleep problems, hypervigilance, and an exaggerated startle response. It was indicated that in spite of progress, he continued to experience clinically significant levels of symptoms and negative impact on functioning. VA treatment notes from 2008 show that the Veteran continued to take Trazadone to help him sleep, and indicated that he had stopped attending one-to-one therapy. VA psychiatric examination in April 2007 indicated that the stress that caused the PTSD, which the examiner believed was exhibited during the interview, included an anti-American mob in Frankfurt which displayed riotous behaviors around the Veteran and his German girlfriend, while yelling racial epithets. The examiner indicated that the source of the Veteran's PTSD was being in a riot with the risk of death in Frankfurt in 1972. The Veteran was isolated, withdrawn, and fearful to go outside of his home due to crowds, almost to the point of being phobic. He had an increased startle reaction, night sweats, and broken sleep such that he rarely obtained more than 5 to 6 hours of sleep. He had a short fuse, but recognized that he had a terrible temper and did his best to be aware of it at all times. He was anxious, but not depressed. He did not exhibit psychotic problems. The examiner observed that the claims folder had various indicators regarding the Veteran's PTSD, to include statements that it was due to active duty in 1972 as described by the Veteran. The Veteran took prescribed Wellbutrin. The Veteran reported that he could not keep a job, avoided people, had no friends or pets, performed perimeter checks, and stayed at home because of fear of attack, particularly by a crowd, but even by individuals. The examiner indicated that in spite of the history of poly substance abuse in and out of service, he believed the Veteran's story, as did Dr. Matloff according to his letter. On examination, the Veteran was anxious, clinically depressed and extremely hypervigilant, with a markedly increased startle reaction, as he jumped from his chair when his cell phone rang unexpectedly. The examiner indicated that in spite of the Veteran's poly substance abuse history, the Veteran seemed to be telling the truth and was a valid historian. There was no impairment of thought process or communication. The Veteran's memory was intact; judgment and insight adequate; and from a clinical standpoint he seemed to have one of the most severe cases of PTSD that the examiner had ever evaluated. The examiner indicated that the Veteran was a victim of personal assault, considering the riots in 1972. The Veteran appeared to be clean and sober from mind altering substances. The examiner diagnosed PTSD secondary to the riots in Frankfurt, Germany, and assessed the Veteran as having a GAF score of 50. The examiner indicated that in his opinion there was total occupational and social impairment due to PTSD signs and symptoms. An April 2009 letter from VA clinical psychologist Susan Tate, Ph.D., indicated that she had provided assessment, cognitive behavioral therapy and recovery-oriented support services to the Veteran since April 2007. She indicated that the Veteran consistently experienced symptoms to include: re-experiencing symptoms related to trauma experienced during military service (intense physiological and psychological distress at reminders of the trauma, nightmares), avoidance and numbing (avoidance of crowds, avoidance of any unknown environment, emotional detachment, diminished interest in activities, restricted range of affect), and increased arousal (heightened startle response, hypervigilance, poor sleep, irritability and anger). In addition, depression symptoms included sadness, loss of interest and pleasure, low self-esteem (worthlessness), fatigue, and sleep difficulties. The Veteran experienced trauma during his military service that resulted in these symptoms, specifically a terrorist bombing of Army headquarters across the street from his workplace, which included the killing of military personnel. These symptoms were documented in his clinical record and caused significant impairment. Dr. Tate indicated that the Veteran had been unable to secure employment since 1992 and had no social support network. Dr. Tate diagnosed the Veteran as having PTSD and major depressive disorder, and assigned a Global Assessment of Functioning (GAF) score of 30. At his Board hearing in May 2009 the Veteran indicated that on May 11, 1972, at the 5th Army Headquarters, he heard and felt an explosion that was very loud and seemed to shake the building, startling him and causing him to believe the war had arrived. He indicated that he went to the sergeant's quarters awaiting instruction and believing that he would be issued a weapon. Hearing sounds that he identified as war, and without a weapon, he believed he was going to die and feared for his life. The following morning he was informed that there had been a terrorist bombing in a building across the street by the Baader Meinhoff gang and that an officer had been killed. The Veteran reported that since service he had received treatment for PTSD from the VA Medical Center in La Jolla. In February and March 2010 the Defense Personnel Records Information Retrieval System indicated that the United States Army Europe and 7th Army Station List for December 31, 1972, documents that the 18th Finance Section was stationed at the Creighton Abrams Building in Frankfurt, Germany. Morning reports from the 18th Finance Section for 1972 showed that they were billeted at #3804 Kaserne Barracks, Frankfurt, within three blocks to the sought of the Creighton Abrams Building. The United States Department of Homeland Security's Global Terrorism Database documented that the 5th Corps Headquarters in Frankfurt, Germany, was bombed May 5, 1972, by members of the Red Army Faction, and one individual was killed while 13 others were wounded. The Veteran was afforded a VA psychiatric examination in July 2011 wherein his history, to include anger management and coping classes, and drug rehabilitation in 2001 was reviewed. It was indicated that he had a history of arthritis, to include in his knees, and that he used hydrocodone for pain management. The Veteran's medical history included the use of anti-depressant medication; specifically, Wellbutrin for mood. The Veteran reported that he was divorced in 1992, and had two children and a girlfriend. He indicated that he spent most of his time alone, and did not enjoy being around others, although he used to hang around members of a motorcycle club. There was no history of suicide attempts, violence, or assaultiveness. The examiner indicated that the Veteran appeared mildly intoxicated during the interview, and although he denied drug use he indicated that he took pain killers for his arthritis. On examination the Veteran was clean, restless, and with rambling speech. His attitude toward the examiner was indifferent; his affect constricted; his mood anxious and his attention intact. He was oriented to person, time and place. His thought process was rambling. Thought content included ruminations; he did not experience delusions or hallucinations and he understood the outcome of his behavior. His intelligence was average, and he partially understood that he had a problem. He reported that his sleep was at times very broken, such that he slept in two hour increments. He did not exhibit inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal or suicidal thoughts. He interpreted proverbs appropriately. He was able to maintain minimum personal hygiene, and there was no problem with activities of daily living. His remote memory was normal; however, his recent and immediate memory were mildly impaired. He reported that at times his memory was fine, but at other times he was confused and could not recall what he was told, and that he repeated things a lot. The Veteran discussed his stressor; specifically, an accident involving actual or threatened serious injury or death to others in Frankfurt, Germany, during May 1972 when the 5th Army Headquarters, near to where he was located, were bombed. He indicated that he experienced intense fear, helplessness, and feelings of horror. His symptoms included recurrent distressing dreams of the event, markedly diminished interest or participation in significant activities, feeling detached or estranged from others, difficulty falling or staying asleep, and an exaggerated startle response. The symptoms were chronic. There was not significant distress or impairment in social, occupational or other important areas of functioning. The Veteran reported that his dreams were fairly chronic, and always about being attacked, making him feel violent. Otherwise, his symptoms were considered minimal and transient. The Veteran appeared to be in tact most of the time, although he had some mild sleep issues and mild social isolation that he attributed to stress exposure. The Veteran was capable of managing financial affairs. The Veteran was unemployed, and had been for 10 to 20 years, stating that he did not know why he could not work, but that he sometimes quit jobs or was sometimes told not to return. The examiner indicated that the Veteran did not meet the criteria for a diagnosis of PTSD, but rather diagnosed opiod dependence, polysubstance dependence. The examiner indicated that in the past the Veteran had reportedly used a variety of drugs, and he denied current use with the exception of prescription pain killers, which he appeared to be dependent on. He did not otherwise meet the criteria for a mental disorder, and was assessed with a GAF score of 50. The examiner indicated that the Veteran's deficits appeared to be the result of drug use that preceded military service. The examiner indicated that the mental disorder symptoms were not severe enough to interfere with occupational and social functioning. The examiner indicated that although service treatment records had been reviewed, there was no evidence of any consequence, and VA treatment records had been reviewed and showed treatment history for alcohol and drug issues. The examiner opined that the Veteran did not meet criteria for any mental disorders at that time and his primary issues revolved around a long history of drug and alcohol abuse/dependence. In sum, the Veteran denied current illegal drug use, but stated that he drank and took prescription drugs. He appeared intoxicated at the time of the interview. The examiner opined that the intoxication was opiod induced according to the Veteran's speech, appearance and behavior. The opinion was rationalized based on the examiner's years of clinical experience and expertise in the field of drug and alcohol counseling. In August 2011 the Veteran indicated his disagreement with the most recent examination, relaying his belief that the examiner met him with disdain and attacked his character, and that the interview was limited as she focused on writing. He expressed disagreement with the examiner's indication that he appeared lethargic, and emphasized that he had rushed to return from a trip visiting his ailing mother in order to attend the appointment, and that he only took prescribed medications. He relayed that his appearance conformed to what he identified as his cultural heritage, and that although he had a beard and dreadlocks, he bathed, brushed his teeth, wore deodorant, cut his nails, and dressed in clean clothes. An August 2011 letter was received from the Veteran's neighbor, JN Green, who knew the Veteran at that time for 10 years, and who self-identified as having post graduate level studies in psychology and experience reading and understanding medical records. Ms. Green discussed the Veteran's reported in-service stressors, to include the riot and bombing in Germany, involving the Baader Meinhoff group, as part of the Red Faction Army, which was against the United States presence in Vietnam, and conducted bombings such as that in Frankfurt in 1972. She discussed that strikes occurred in Germany, and demonstrations for unification of East and West Germany, and that it was possible that the Veteran had walked into the midst of some group staging a march, and that it would have been rare to see a black person at that time in Germany. Ms. Green reported that the Veteran stayed with her for a month during which time his startle reflex was noticeable; for example, he jumped and hollered whenever his cell phone rang. She recalled a New Year's Eve celebration with him, when she witnessed him jump when the fireworks began and noticed that he remained tense from then forward. She reported that he experienced sleep disturbance, including difficulty falling asleep and awaking throughout the night to check the perimeter. She reported that the Veteran experienced dreams in which he was chased by a crowd. She discussed the Veteran's most recent examination and contended that the diagnosis of opiod dependence was likely related to his prescribed pain medications. She indicated that the Veteran told her he was embarrassed when during the examination his phone range and he displayed his typical response. She indicated that in regards to the examiner's report that the Veteran appeared intoxicated, possibly opiod induced, she had seen the Veteran prior to his appointment and disagreed. She reported that the Veteran's personal hygiene was very good, that if he walked with a limp he tended to do this in the morning, and that the Veteran tended to have good eye contact, move quickly without signs of jitteriness or nervousness, was seldom slow in behavior unless deliberately so or relaxing, and presented his thoughts clearly and concisely, without slow or slurred speech, even if had had recently taken pain medication. The neighbor emphasized the Veteran's fear of terrorist activity involved the bombing in Germany, and involvement in a race riot, and that his treating psychiatrists indicated the PTSD was related to the bombing incident in consideration of the VA Fact Sheet of 7/12/2010 on PTSD. In August 2012 the Veteran's representative emphasized the medical evidence from Jeffrey Matloff, Ph.D., in 2003, and from Susan Tate, Ph.D., in April 2009, assessing the Veteran with PTSD in relation to his in-service stressors. The representative reviewed the research results from JSSRC discussing the Veteran's stressors in suggesting a grant of entitlement to service connection was warranted. Left knee disability The Veteran seeks service connection for a left knee disability. At his May 2009 Board hearing, the Veteran testified that it was his belief that his current left knee disability had been caused by constant running as well as jumping during airborne training. In particular, he contended that as part of his training, he had to jump numerous times from a tower and run several miles daily. The Veteran reported that he was barely conscious of knee difficulty, finding himself more aware of pain in his ankle where he had a metal plate inserted. As the Board initially found in December 2009, the Veteran's testimony is credible. He claims that he has experienced knee pain since service. Service treatment record from July 1979, during which time he was in the Reserves, indicates that he experienced a very painful left knee when walking that was the result of an old injury, two weeks earlier. He states the he was exercising and his knee seemed to give way, but there was no evidence of edema or trauma. It was indicated that he had probably strained a muscle or ligament, and that he had full range of motion although he reported discomfort on full extension and flexion, but not with passive motion. There was no locking or swelling of the joint, and no treatment was indicated. In July 2003 the Veteran claimed entitlement to service connection for a left knee disability. Additionally, the record on appeal contains medical evidence dated in 2002 and 2003 showing that the Veteran has been diagnosed as having osteoarthritis of several joints, to include the knee (the right or left knee is not specified). March 2002 VA treatment note indicated that the Veteran reported orthotics were helping him, and that he was not experiencing the popping in his knees that he had earlier. September 2002 included a medical history of arthritis of several areas to include the knee, although which knee was not specified and the treatment notes focused on the shoulder. At his November 2006 RO hearing the Veteran indicated that his knee locked up sometimes, but that he had not received knee treatment for "quite some time." He indicated that his knee problem had begun on his initial tour of active duty, after boot camp, during Airborne training at Fort Benning, Georgia. The Veteran was afforded a VA joints examination in April 2010 for his left knee disability. He reported that while at jump school in Fort Benning, Georgia in 1970 he developed pain in his left knee while running. He reported that since that initial episode of pain he continued to experience aching pain in the left knee throughout service, although it was not severe enough to warrant medical attention. He reported that he currently experiences occasional locking and giving way of his left knee, particularly when climbing or descending stairs. He reported that he could walk for approximately one mile, sit for 20 to 30 minutes before his knees began to ache, and stand for 30 to 45 minutes before he needed to sit. The pain was described as a 2 or 3 on a scale to 10, and located behind the patella. It was only occasionally present after he walked or stood more than usual, which would be approximately 2 or 3 times a month. When the pain flared up the Veteran limited his walking, standing, or sitting for 1 to 2 days until it resolved. The Veteran did not take pain medications for his knees. He did not describe any specific limitations to his daily activities. On examination, the left knee was normal to inspection. There was mild tenderness to palpation with patellar manipulation. No crepitus was present. Range of motion testing revealed flexion to 130 degrees with pain, and extension to 130 degrees without pain. There was no additional limitation of motion with repetitive movement due to pain, fatigue, weakness, lack of endurance, or incoordination. Approximately 5mm of varus instability was present at 30 degrees of flexion. Anterior and posterior drawer test and McMurray's test were negative. X-rays of the left knee were normal. Diagnosis was of musculoligamentous strain of the left knee and varus instability, mild. These diagnoses were responsible for minimal daily activity limitations. The examiner reviewed the claims folder and examined the knee. He indicated that based on the fact that the Veteran completed service with no complaints regarding his knee, after what was described as a relatively minor injury early in his military career, and the fact that he did not describe any significant limitations to activities following separation from service, it was his opinion that the left knee disability was less likely than not caused by or a result of service. The examiner indicated that although it was not impossible that the minor injury sustained during airborne training could have lead to current left knee disability, this was very unlikely. The Veteran's representative in August 2012 emphasized that the Veteran continued to contend that he had a left knee disability caused by constant running and jumping during airborne training, and that his examination had shown occasional locking and giving way of his left knee, and pain at a level of 2 or 3 of 10, located behind the patella. Legal Analysis PTSD In summary, the Veteran has discussed the type of work he engaged in while in service, the stressors he experienced, and his PTSD-related symptoms and treatment. Specifically, the Veteran described how while in service he felt and heard an explosion while stationed with the 18th Finance Section in Frankfurt, Germany, and only later learned that it was from a bombing of the 5th Army Headquarters by a terrorist group. The Veteran indicated that he feared for his life while in service, explaining how it was particularly disconcerting to believe the war had found him in Germany, yet be unarmed. As such, the Veteran has competently and credibly recounted stressor incidents related to his fear of hostile military action in that his physical integrity was threatened and the Veteran experienced a state of fear. The Veteran specifically detailed fear experienced when he heard and felt an explosion and believed that the war was also in Germany, and only later found out that it was a bombing by a terrorist group. His discussion of his experience is consistent with the place, type and circumstance of his service as he described it, as well as is shown by the Defense Personnel Research. In addition, there is evidence showing that a VA psychiatrist or psychologist has confirmed that the Veteran's experience with the bombing is adequate to support a diagnosis of PTSD, and that the Veteran's symptoms are related to the claimed in-service stressor. The Veteran is certainly competent to attest to in-service events. In this case, after carefully considering the record, the Board finds that the Veteran's statements regarding his claimed in-service stressors are credible. In particular, the Veteran had retold his story of what occurred in service on various occasions to the Board and to various medical professionals in the course of receiving treatment. Although some details varied with the retelling, the Board finds that the Veteran was generally consistent in his accounts. In addition the Veteran consistently recounted an experience akin to personal assault, in particular being chased by an anti-American mob while in Frankfurt, Germany. This incident has also been considered adequate by a VA medical examiner to support a diagnosis of PTSD, although he was not a psychiatrist or psychologist. The evidence supports a finding that a grant of service connection is warranted for PTSD under the amended regulation. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.304(f)(3); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Alternatively, resolving all reasonable doubt in favor of the Veteran, and in light of the consistent and credible statements regarding in-service personal assaults, the Board finds that the Veteran's PTSD was caused by his experiences with a mob in service. As the VA psychologist linked the trauma from the assault to the development of PTSD, the Board finds that the evidence is at least in equipoise as to whether he has psychiatric disability as the result of a personal assault in service, and the Board will resolve all reasonable doubt in favor of the Veteran. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See 38 U.S.C.A. § 1153(a) (West 2002 & Supp 2011); 38 C.F.R. § 3.303(a); Jandreau; see also Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). A layman is competent to report what he or she experiences through one of the senses. See Layno v. Brown, 6 Vet. App 465, 470 (1994). The Board has carefully considered the Veteran's lay assertions in this regard; however, the etiology of left knee musculoligamentous strain and varus instability, requires specialized training for a determination as to causation, and is therefore not susceptible of lay opinion. In this instance, no causal connection has been proposed between the claimed left knee disability and service, except for the Veteran and his representative's own statements that are not competent. Specifically, although a layperson is competent to discuss his symptomatology, he is not competent to provide a medical nexus. In contrast, the April 2010 VA examiner indicated that the left knee disability was "less likely than not" related to service. This opinion, substantiated by sound reasoning discussing the Veteran's lack of symptoms causing functional limitations since service is entitled to substantial probative weight. In addition, although there are references to osteoarthritis, the medical reports do not distinguish whether the left knee is specifically involved in spite of the Veteran's reported history of arthritis in both knees, and more importantly, the records do not show that it was evidenced within a year of separation from service. As such that there is no indication that the Veteran is entitled to presumptive service connection for a left knee disability. Therefore, inasmuch as the evidence weighs against a relationship to service, the record affords no basis to grant service connection for a left knee disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. The preponderance of the evidence is against the claim, and the claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011); see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Service connection for an acquired psychiatric disability, to include PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. Service connection for a left knee disability is denied. ______________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs