Citation Nr: 1301094 Decision Date: 01/10/13 Archive Date: 01/16/13 DOCKET NO. 05-35 760 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and/or an anxiety disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S.K.C. Boyce, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1960 to July 1963. This matter is before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). In a November 2010 Order, the Court endorsed a November 2010 Joint Motion for Remand; vacated the portion of a February 2009 Board decision that, in pertinent part, denied entitlement to service connection for PTSD; and remanded the matter for compliance with the instructions in the Joint Motion. In June 2011, the Board remanded the appeal for additional development pursuant to the November 2010 Order and Joint Motion. This claim for service connection for PTSD initially came before the Board on appeal from a January 2004 rating decision of the United States Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, along with subsequent rating decisions dated February 2004 and December 2004, confirmed the RO's initial February 2003 denial of service connection for PTSD. In June 2008, the Board remanded the appeal to provide the Veteran with a requested hearing before a Veterans Law Judge (VLJ), and that hearing was held before the undersigned VLJ in December 2008. The issue of service connection for PTSD has been recharacterized as reflected on the title page in order to account for the Veteran's recent change in diagnosis. See September 2012 VA examination; February 2012 VA treatment records; see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the Board must consider "the claimant's description of the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of that claim" in considering all alternative conditions within the scope of the claim filed); Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (holding that the Board must consider all claims raised either by the appellant or the evidence of record). The February 2009 Board decision also dismissed claims for entitlement to a rating in excess of 10 percent for service-connected hemorrhoids and entitlement to a compensable rating for a left varicocele. As the November 2010 Order and Joint Motion show that these issues were dismissed by the Court, the Board need not address them further. FINDINGS OF FACT 1. The Veteran does not have a present disability of PTSD or any other acquired psychiatric disorder, other than an anxiety disorder. 2. The preponderance of the evidence is against a finding that the Veteran's anxiety disorder is related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and/or an anxiety disorder, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in exhaustive detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (explaining that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim on appeal. Therefore, the Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed in the following discussion. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Due Process VA has met its obligations under 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). The Court has held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio, 16 Vet. App. at 186-87; 38 C.F.R. § 3.159(b). In Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and provide the claimant with notice of what additional information and evidence, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim: (1) Veteran status, (2) existence of a disability, (3) a connection between the Veteran's service and the disability, (4) degree of disability, and (5) effective date. See id. at 490; see also 38 U.S.C.A. § 5103(a). Compliance with the first Quartuccio element requires notice of these five elements. See id. Here, letters dated in December 2002, March 2003, and April 2003 informed the Veteran of the evidence that VA would seek to provide and the evidence that he was expected to provide, and a letter dated December 2005 informed the Veteran of the evidence necessary to substantiate his claim for PTSD. The December 2005 letter also advised the Veteran to identify any sources, military or non-military, which may provide information concerning the incident(s) alleged, to include a rape crisis center, counseling facility or health clinic, or any military, police, or other authorities. Additionally, he was informed that, if he confided in a roommate, family member, chaplain, clergy, or fellow service person, such individual could submit a statement concerning their knowledge of the incident(s). Moreover, the Veteran was advised that he should indicate whether she experienced any of the following: visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; sudden request for change in Military Occupational Specialty or duty assignment; increased use of leave without immediate reason; changes in performance evaluations; episodes of depression, panic attacks, or anxiety; increased or decreased use of prescription medication; alcohol or substance abuse; increased use of over the counter medication; disregard for military or civilian authority; obsessive behavior such as over-eating or under-eating; tests for HIV or sexually transmitted diseases; unexplained economic or social behavior changes; or pregnancy tests around the time of the incident. In summary, the Veteran was advised that evidence from sources other than his service records or evidence of behavior changes may constitute credible supporting evidence of his claimed stressors, and he was given the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. See 38 C.F.R. § 3.304(f)(5); Bradford v. Nicholson, 20 Vet. App. 200, 206 (2006); Patton v. West, 12 Vet. App. 272, 278 (1999). Although the December 2005 letter was sent after the initial adjudication of the Veteran's claim, his claim was readjudicated in a February 2006 Supplemental Statement of the Case (SSOC) and in a November 2012 SSOC, and the issuance of fully compliant VCAA notification followed by readjudication of the claim, such as an Statement of the Case (SOC) or SSOC, is sufficient to cure a timing defect. See Prickett v. Nicholson, 20 Vet App. 370, 376 (2006). Therefore, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). The Board also concludes that VA's duty to assist has been satisfied. The Veteran's service treatment records, service personnel records, Social Security Administration records, and all available VA treatment records have been associated with the file. Two requests for additional VA treatment records from the Jamaica Plains VA Medical Center, dated March 1982, were sent in June 1985 and August 1985, but a negative response was received. As VA has been advised that the records do not exist, further efforts to locate them would be futile, and there is no continuing duty to attempt to obtain these records. See 38 U.S.C.A. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(3). Additionally, all private medical records identified by the appellant have been obtained to the extent possible. Letters requesting his identified private treatment records from a previous hospitalization in July 1983 and records from his previous employer were sent in June 2003 and August 2003, and the Veteran was so informed. Records from the July 1983 hospitalization were already present in the claims folder at the time of the request, and, in a September 2003 statement, the Veteran informed VA of his efforts to obtain his records from his employer. In January 2004, and he ultimately submitted a summary of his records from his employer as his original records were no longer available. The appellant has at no time referenced any additional outstanding records that he wanted VA to obtain or that he felt were relevant to the claim on appeal. As such, all obtainable private treatment records have been associated with the claims folder. See 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c)(1). For service connection claims the duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). In order for a VA examination to be adequate, the examiner must fully consider the Veteran's relevant medical history, including the lay statements of record, and describe the disability in sufficient detail to facilitate a fully informed evaluation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). As the probative value of the medical opinion obtained is derived from a factually accurate, fully articulated, and soundly reasoned opinion, it is important that any VA examination report obtained contain clear conclusions, supporting data, and an explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-04 (2008). The Veteran was afforded VA examinations in December 2011 and September 2012. The examination reports were provided by a medical professionals following a thorough examination and interview of the Veteran, as well as a complete review of the claims file, as described in the reports. The examiners obtained an accurate history, and the examination reports show that the examiners listened to and considered the Veteran's assertions. Furthermore, the examiners presented a clear factual foundation and reasoned basis for the conclusions that were reached. The December 2011 VA examiner's inability to address the change in diagnosis shown in the February 2012 VA treatment records was corrected upon reexamination in September 2012. See Roberson v. Shinseki, 22 Vet. App. 358, 366 (2009); Barr, 21 Vet. App. at 310-11. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such error remaining is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Furthermore, the Board is satisfied that the RO has substantially complied with the Board's June 2011 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that it directed the RO to obtain the Veteran's service personnel records and contemporaneous treatment records, to make appropriate efforts to verify his claimed stressors, and to provide the Veteran with an appropriate VA examination. In this regard, the AMC obtained the Veteran's service personnel records, completed all appropriate actions to verify his claimed stressors, obtained his recent VA treatment records, requested information necessary to obtain any additional private treatment records, and provided him with the requested VA examination, as discussed above. The Veteran's claim was readjudicated in a November 2012 Supplemental Statement of the Case (SSOC). Lastly, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearings, the VLJ specifically clarified the issues on appeal. See December 2008 Board Hearing Trans., p. 2. Additionally, throughout the hearing, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding as any indication of the existence of such evidence arose. Moreover, neither the Veteran nor his representative have asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the December 2008 Board hearing. The hearing focused on the elements necessary to substantiate the Veteran's claim, and the Veteran and his representative, through testimony, argument, and questions, demonstrated actual knowledge of the elements necessary to substantiate the claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and the Board will proceed to adjudicate the claims based on the current record. II. Service Connection The Veteran contends that he currently suffers from PTSD due to several stressors that occurred in service, including two alleged instances of sexual assault; an accident involving live mortar fire training exercises during basic training that caused injuries to other soldiers; an incident during basic training where the Veteran was intentionally exposed to tear gas in an enclosed space for a prolonged period; a "top secret" plane crash with multiple casualties in Munich, Germany, in 1962; the torturing of a prisoner; and the suicide of an agent in Munich around 1962. He further contends that he was treated for a nervous breakdown in service, and his parents have submitted statements attesting to the changes in his behavior that they observed upon his return from service. Lastly, he contends that he served in a hostile environment during his military service as he was ordered to use the fully loaded .45 caliber sub-machine gun and .45 caliber pistol on the back of the access door to the cryptography center, a windowless steel room, to deny entry to any person not named on the access list, and lived under constant fear of being abducted for his knowledge of valuable classified information. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Cosman v. Principi, 3 Vet. App. 503, 505 (1992); 38 C.F.R. § 3.303(d). In order to establish service connection, the evidence must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. To establish entitlement to service connection for PTSD, in particular, there must be: (1) medical evidence of a diagnosis of a mental disorder that conforms to the DSM-IV, as directed by 38 C.F.R. § 4.125(a); (2) credible supporting evidence that a claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The evidentiary burden of establishing the occurrence of a claimed stressor is reduced where (1) there was a diagnosis of PTSD during service; (2) the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat; (3) the claimed stressor is related to "fear of hostile military or terrorist activity," and a psychiatrist or psychologist employed by VA or with whom VA has contracted confirms that the claimed stressor is adequate to support a diagnosis of PTSD and the Veteran's symptoms are related to the claimed stressor; (4) the Veteran was a prisoner of war, or (5) the stressor concerns a personal or sexual assault. See 38 C.F.R. § 3.304(f); see also 75 Fed. Reg. 39843-39852 (July 13, 2010) (detailing the inclusion of the new provision pertaining to stressors related to "fear of hostile military or terrorist activity"). Therefore, as noted above, if none of these exceptions apply, the Veteran's claimed in-service stressor must be corroborated by credible supporting evidence. Doran v. Brown, 6 Vet. App. 283, 288-289 (1994). Nevertheless, in all cases, the first element needed to establish a claim for service connection for PTSD under 38 C.F.R. § 3.304(f) is medical evidence establishing a current and unequivocal PTSD diagnosis in accordance with 38 C.F.R. § 4.125(a). See Cohen v. Brown, 10 Vet. App. 128, 139-140 (1997). In Cohen, the Court explained that, in making a PTSD diagnosis, mental health professionals "are presumed to know the DSM-IV requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis." Consequently, where there is a current diagnosis of PTSD by a qualified mental health professional, the sufficiency of the claimed in-service stressor is presumed. Id. at 144. However, only the sufficiency of the claimed stressor is presumed, not the actual occurrence of the stressor. Just because a physician or other health professional accepts the Veteran's description of his experiences as credible and, as a result, diagnoses PTSD, does not mean the Board is required to grant service connection for PTSD. See Wilson v. Derwinski, 2 Vet. Ap. 614, 618 (1992). The Court further explained that a determination as to the sufficiency of the stressors alleged by the Veteran, in terms of DSM-IV's two requirements that (1) a person must have been "exposed to a traumatic event" in which "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and (2) "the person's response [must have] involved intense fear, helplessness, or horror," is a medical question requiring examination and assessment of the Veteran by an appropriate mental-health professional." Cohen, 10 Vet. App. at 141-42. Lastly, the Court cautioned that a stressor need not be limited to just one single episode, as a group of experiences also may affect an individual and lead to a diagnosis of PTSD. Id. at 142. When evaluating a claim for disability benefits, VA must give due consideration to all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Generally, the Board will determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). Lay evidence can be competent and sufficient to establish a diagnosis if (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Furthermore, a lay witness is also competent to testify to the occurrence of an in-service injury or incident where the issue is factual in nature. See generally Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lastly, a layperson may be competent to testify to the manifestations of a chronic condition during service or a presumptive period or to continuity of symptomatology. See generally Hickson, 12 Vet. App. at 253; see also Buchanan, 451 F.3d at 1337 (holding that the Veteran may be competent to testify to chronicity of psychiatric symptoms in service and continuity of psychiatric symptoms after service); Culver v. Derwinski, 3 Vet. App. 292, 297-98 (1992) (holding that the Board erred where it failed to address lay testimony regarding the Veteran's alleged nervous breakdown shortly after discharge from service). Once evidence is determined to be competent, the Board must determine whether the evidence is credible. In assessing the credibility of the evidence, the Board may properly consider facial plausibility, internal consistency, consistency with the other evidence of record, the demeanor of the witness if oral testimony is given, self-interest, and possible bias. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995); see also Gardin v. Shinseki, 613 F.3d 1374, 1379-1380 (Fed. Cir. 2010); Buchanan, 451 F.3d at 1337; Pond v. West, 12 Vet. App. 341, 345-47 (1999). The Board must weigh all of the competent and credible evidence to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the Veteran. Washington v. Nicholson, 19 Vet. App. 362, 366-67 (2005); Owens v. Brown, 7 Vet. App. 429, 433 (1995). In doing so, equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert, 1 Vet. App. at 53; see also 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Here, the preponderance of the evidence is against finding that the Veteran has a diagnosis of PTSD. As the evidence does not establish a diagnosis of PTSD, this condition cannot be associated with his military service and service connection cannot be granted for that psychiatric disorder. The Veteran has consistently reported that he has been diagnosed with PTSD and has undergone regular treatment for PTSD. See August 2008 hearing testimony, November 2003 statements, and January 2003 statement. Additionally, the Veteran's caretaker submitted a statement in April 2003 wherein she described both her research into PTSD, and her opinion that this research combined with her observation of the Veteran supports a diagnosis of PTSD. Lastly, in a January 2004 statement, an employee assistance counselor with the Veteran's former employer reported that the Veteran was diagnosed with and treated for PTSD and depression in July 1983. The Veteran is competent to report his diagnoses of PTSD. See Davidson, 581 F.3d at 1316. Furthermore, with the exception of the specific date of diagnosis provided at his August 2008 hearing, his assertions regarding his diagnosis and treatment for PTSD are corroborated by his VA treatment records. Therefore, the statements on the general character of his diagnosis and treatment are credible. See Caluza, 7 Vet. App. at 511. However, as his August 2008 hearing testimony on the date of his first PTSD diagnosis, allegedly in the 1990s, was explicitly of an uncertain nature and is contradicted by his VA treatment records, this statement is not credible. Id. Furthermore, while the competency of the employee assistance counselor is conceded, as the January 2004 statement indicates that he has a master's degree and is a certified employee assistance professional, the records of the Veteran's July 1983 hospitalization in the claims folder show a "final diagnosis" of alcohol dependence and possible depression, and no diagnosis of PTSD. Therefore, as the statement by the counselor, provided more than 20 years after the hospitalization at issue, conflicts with the contemporaneous records of that hospitalization, that statement is not credible. Id. Lastly, while the Veteran's caretaker is competent to report the symptoms that she has observed over the 30 years that she has known the Veteran, she is not, as a layperson, competent to diagnose the Veteran with PTSD on the basis of the criteria in the DSM-IV. See Jandreau, 492 F.3d at 1377 n.4 (explaining that some diagnoses are not a simple and identifiable conditions, like a broken leg); see also, e.g. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). As noted in her October 2012 statement, she does not have the relevant psychological or psychiatric expertise to provide a competent psychiatric diagnosis. The most probative medical evidence of record supporting a diagnosis of PTSD is a November 2003 VA psychiatric consultation report from the VA community-based outpatient clinic (CBOC) in St. Augustine, Florida, which shows a DSM-IV, Axis I, diagnosis of chronic PTSD, depression not otherwise specified (NOS). The Veteran was referred to this psychiatrist by his VA psychologist following treatment for reported PTSD symptoms, without a conclusive diagnosis, at the VA CBOC in Daytona, Florida, in 2001 and 2002. At the November 2003 evaluation, the Veteran reported a history of treatment for PTSD, as well as a history of flashbacks, isolative behavior, poor concentration, memory problems, and recurrent memories. He also reported several psychological stressors in service, including seeing dead bodies from a plane crash, witnessing torture, and sexual assault. He described current symptoms of chronic sadness, suspicious thoughts, sleeplessness, and irritability. The VA psychiatrist observed that the Veteran was curiously non-specific on other symptoms; for instance, he would not conclusively deny suffering from hallucinations. On examination, his attitude was observed to be restless, defensive, and guarded. His mood was described as dysphoric and irritable, with a congruent but restricted affect. Despite his reported history of symptoms, he exhibited no problems with memory or thought processes on examination. Subsequently, an April 2004 treatment record of a video telepsychiatry appointment and an initial psychiatry assessment dated December 2005 also show diagnoses of PTSD with depression, but in February 2012, the Veteran's treating psychiatrist changed his diagnosis to "anxiety, NOS, rule out cognitive disorder, NOS." The treating psychiatrist noted that the Veteran's atypical symptoms, atypical reported stressors, lack of treatment, and elevated scores on tests designed to test feigning and over-reporting "further cloud the diagnostic picture," although he was not ready to conclusively rule out a diagnosis of PTSD. As of May 2012, the Veteran's problem list also shows a more recent diagnosis of "anxiety state." All other evidence from the Veteran's treatment records is inconclusive. An August 1985 treatment note from the VA Medical Center in Boston, Massachusetts, shows that PTSD was suggested, but not confirmed. Previous mental health treatment records from this time period at this location attributing the Veteran's symptoms to a situational crisis in July 1985 and a possible dysthymic disorder, major depressive episode (MDE), avoidant personality, and emotionally unstable character disorder (EUCD) in June 1983. Later VA treatment records from the CBOC in St. Augustine dated from November 2011 to May 2002 show that the Veteran regularly complained of PTSD symptoms, and worry, anxiety, and suspiciousness were observed, but diagnosis was consistently deferred prior to the November 2003 psychiatric evaluation discussed above. Conversely, in December 2011, the Veteran was provided with a VA examination with a VA psychologist. The psychologist reviewed the Veteran's reported history and symptoms, conducted an examination, and reviewed his complete medical record and determined that the Veteran did not meet the DSM-IV criteria for any mental disorder, including PTSD, as there was insufficient evidence of the criterion C factors, i.e., persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. Furthermore, the examiner administered two tests designed to assess feigned symptoms and both clearly indicated that the Veteran was feigning symptoms of psychiatric and/or cognitive dysfunction as well as memory impairment. Specifically, the Veteran endorsed symptoms and impairment that are highly atypical of individuals with genuine psychiatric or cognitive disorders and his score of 13 out of 50 on the Test of Memory Malingering (TOMM) on both test and retest was significantly below the recommended cutoff scores of 40 or 45 upon the second trial. In summary, the examiner found that the Veteran did not meet the DSM-IV criteria for PTSD and was also unable to assign a Global Assessment of Functioning (GAF) score or otherwise opine as to the Veteran's occupational or social functioning because of the objective evidence indicating that the Veteran provided unreliable data. In September 2012, the Veteran was provided with a second VA examination with a second VA examiner in order to obtain a second opinion on any existing psychiatric diagnosis in light of the Veteran's recent change in diagnosis, as well as a medical opinion, if appropriate. Once again, the examiner found that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. The examiner did find that a diagnosis of "anxiety disorder, NOS" was warranted, but, following a full review of the Veteran's reported history and the history of treatment detailed in his medical records, the examiner determined that it was less likely than not that the Veteran's current symptoms, including any anxiety disorder, were related to his military service because of the number and severity of intervening psychosocial stressors that the Veteran has experienced in the decades following his military service. Where, as here, there are conflicting opinions of record, the Board may favor the opinion of one competent medical expert over another as long as it articulates understandable and valid reasons or bases for doing so. Parrish v. Shinseki, 24 Vet. App. 391 (2011); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). As noted above, most of the probative value of an opinion comes from its rationale or underlying reasoning, not merely from review of the claims file, although that, too, has its importance if evidence in the file, if considered, might affect the outcome of the opinion or its underlying basis. See Nieves-Rodriguez, 22 Vet. App. at 300. Therefore, in summary, in evaluating the probative value of a medical opinion, the Board will assess whether (1) the medical opinion is based on sufficient and accurate facts and data, (2) the medical opinion is the product of reliable principles and methods, and (3) the expert witness has applied the principles and methods reliably to the case. See Nieves-Rodriguez, 22 Vet. App. at 302, citing Fed. R. Evid. 702; see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (explaining that the Board will look at the foundation upon which the opinion is based, including whether the opinion is based on facts provided by the Veteran that have been found to be inaccurate). Accordingly, it is imperative that the medical expert provide the sort of factually accurate, fully articulated, and sound reasoning that allows the Board to assess whether the conclusion provided is the product of valid medical analysis applied to the significant facts of the particular case. Id. at 304. In other words, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Id. at 301, citing Stefl, 21 Vet. App. at 124. Here, the diagnostic findings of the VA examiners outweigh the November 2003 diagnosis by the Veteran's treating psychiatrist as the outcome of the tests administered for the purpose of assessing the validity of the Veteran's responses indicate that the facts the Veteran has provided to his psychologists and psychiatrists have been inaccurate. See Reonal, 5 Vet. App. at 461. Further, upon review of the post-assessment findings of the December 2011 VA examiner, the Veteran's treating psychiatrist explained that the Veteran's diagnosis was changed to reflect the likelihood of symptom exaggeration, thereby illustrating the relevance of that data and its application to the diagnostic criteria in the DSM-IV to any sound diagnostic determination. See Nieves-Rodriguez, 22 Vet. App. at 304. Therefore, as the outcome of the testing administered by the VA examiners was not known at the time of the November 2003 psychiatric evaluation and the Veteran's current psychiatrist changed his diagnosis as a result of the outcome of the testing administered at the VA examination, the Board finds that the opinions of the VA examiners outweigh the diagnosis of PTSD provided by the Veteran's treating psychiatrist in November 2003 as the evidence shows that the November 2003 psychiatrist was unaware of facts and data shown to be critical in providing an accurate diagnosis. See id. at 302. Furthermore, the November 2003 report does not include a formal evaluation of the individual DSM-IV criteria, which limits the Board's ability to weigh the probative value of the diagnosis provided against the detailed diagnostic analysis provided by the VA examiners. See id. at 304. The other diagnoses of record were noted in accordance with the findings of the November 2003 VA psychiatrist and contain no additional justification for the diagnosis of PTSD. Therefore, as they are not substantiated by any additional rationale, the later diagnoses shown in his treatment records from other VA psychologists do not outweigh the findings of the VA examiner. See id. at 301. Lastly, the earlier diagnoses of record in 1985 and 2001 to 2002 are either inconclusive, speculative, or do not support a diagnosis of PTSD. Lastly, the Veteran's lay statements reporting a diagnosis of PTSD and his caretaker's accounts of his symptoms of PTSD, which, as discussed above, were found to be competent and credible, do not outweigh the reasoned explanations for finding against a diagnosis of PTSD provided by the VA examiners due to their relevant medical expertise which allows the examiners to administer and analyze specialized testing in order to more accurately determine whether there is a reliable and sound basis for a psychiatric diagnosis. The first, and perhaps most fundamental, requirement for any service connection claim is that the Veteran has to initially establish he has the claimed condition. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In Brammer , the Court noted that Congress specifically had limited entitlement for service-connected disease or injury to cases where such incidents had resulted in actual disability and that, without this threshold minimum level of proof, there can be no valid claim. To show a current disability, there must be evidence of the condition at some time during the appellate period. Gilpin v. West, 155 F. 3d 1353, 1356 (Fed. Cir. 1998); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves prior to VA's adjudication of the claim). Therefore, absent the required DSM-IV diagnosis of PTSD, service connection for PTSD cannot be granted. 38 C.F.R. §§ 3.304(f); 4.125(a). Furthermore, inasmuch as there is no PTSD diagnosis, PTSD cannot be linked to the Veteran's military service, irrespective of whether the occurrence of a stressor in service has been established. See Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 132, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). The evidence for and against this claim is not so evenly balanced to allow for the application of the benefit-of-the-doubt rule. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 53; 38 C.F.R. § 3.102. Instead, the preponderance of the evidence is against the claim. Therefore, service connection for PTSD must be denied. The Veteran's other psychiatric diagnoses have also been considered. See Clemons, 23 Vet. App. at 5. In Clemons, the Court held that the scope of a mental health disability claim includes any mental disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See id. Consequently, when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Here, the Veteran has been diagnosed with an anxiety disorder with symptoms of depression. However, the November 2012 VA examiner determined that anxiety was less likely than not related to the events in service alleged by the Veteran because of the number and the severity of the intervening psychosocial stressors that the Veteran has experienced in the decades following his military service, as discussed during his interview in December 2011 and November 2012. This opinion is accorded significant probative weight as it was given upon review of the Veteran's entire relevant medical history, including his history of relevant post-service stressors and his history of psychiatric and psychological treatment. See Stefl, 21 Vet. App. at 123. Furthermore, the examiner provided an explanation for the opinion that illustrated his application of the facts, namely, the Veteran's post-service psychosocial stressors and the character of his history of treatment, to the causal principles utilized, specifically an analysis of the chronology, number, and severity of relevant stressors. Nieves-Rodriguez, 22 Vet. App. at 302. No other medical opinion on the etiology of the Veteran's anxiety disorder, NOS, is of record. Therefore, review of the record shows that the greater weight of the evidence is against finding that the Veteran's currently diagnosed anxiety is related to his military service. See Shedden, 381 F.3d at 1167; see generally 38 C.F.R. § 3.303; see also 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 53-56; 38 C.F.R. § 3.102. Additionally, while the record shows that the Veteran has a history of treatment for alcohol dependence, compensation for primary alcohol abuse disabilities and secondary disabilities that result from primary alcohol abuse are precluded as a matter of law under 38 U.S.C.A. §§ 105 and 1110. See Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Lastly, the Board also notes that the Social Security Administration (SSA) determined that the Veteran suffered from an organic brain disease, as opposed to an acquired psychiatric disorder, on the basis of testing which showed considerable cognitive impairment and impairment of memory. However, as the December 2011 VA examiner specifically found that the Veteran's cognitive and memory test data is unreliable due to objective evidence of symptom exaggeration, and there is no indication that the SSA examiners utilized additional measures to validate the responses given by the Veteran. In consideration of the evidence indicating that the Veteran's interview and assessment responses are unreliable, combined with the complete absence of this diagnosis from any of the Veteran's treatment records, the evidence weighs against finding that the Veteran currently suffers from an organic brain disease. See Reonal, 5 Vet. App. at 461. Therefore, there is no need for the Board to consider this diagnosis as an underlying cause of the Veteran's alleged symptoms. Therefore, as the preponderance of the evidence is against finding that the Veteran has a properly diagnosed psychiatric disorder of PTSD, the greater weight of the evidence is against finding that his anxiety disorder is due to his military service, and any disability resulting from primary alcohol abuse is barred as a matter of law, service connection for an acquired psychiatric disorder, to include PTSD and an anxiety disorder, is not warranted and the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine, but, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 53-56. ORDER Service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and/or an anxiety disorder, is denied. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs