Citation Nr: 1301291 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 09-16 635 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD S.K.C. Boyce, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1967 to January 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which found that new and material evidence sufficient to reopen the Veteran's previously denied claim for service connection for PTSD had not been submitted. The RO in Winston-Salem, North Carolina, currently has jurisdiction. In October 2010, the Board found that the evidence submitted by the Veteran in support of his claim was new and material and reopened the claim for service connection for PTSD. The Board then remanded the claim for further development in order to obtain verification of the Veteran's claimed stressors and to provide him with VA examination. In May 2012, the Board found that the VA examination report obtained on remand was inadequate for rating purposes and remanded the Veteran's claim a second time in order to provide the Veteran with a second VA examination to obtain a VA examination report with additional rationale for the examiner's findings. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran does not have PTSD, and the evidence does not establish the existence of any other diagnosable acquired psychiatric disorder. 2. There no evidence establishing the manifestation of a psychiatric disorder in service or within one year thereafter, nor is there evidence establishing a link between any psychiatric disorder and the Veteran's military service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, 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 file. Although the Board has an obligation to provide reasons or bases for its findings and conclusions on all material issues of fact and law, there is no need to discuss, in exhaustive detail, each piece of 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 need not explicitly discuss every individual piece of evidence in the record). Accordingly, the analysis below will focus on an evaluation of the material evidence of record and whether this evidence substantiates, or fails to substantiate, the claim on appeal. Therefore, the Veteran should not assume that the Board has overlooked evidence that is not explicitly discussed in the following discussion. See generally Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Due Process Under the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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). This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). 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 following five elements of the claim in order to meet the first Quartuccio element: (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) the effective date. Id. at 490; see generally 38 U.S.C.A. § 5103(a). Here, a letter dated in November 2007 informed the Veteran of all three Quartuccio elements required by 38 C.F.R. § 3.159(b), as stated above, including notice of how VA determines disability ratings and effective dates. This letter also provided information specific to claims for service connection for PTSD, including a request for the specific details of the incident(s) that allegedly resulted in PTSD; a request for any records of relevant private treatment or VA treatment, including any treatment at a Vet Center; notice of the evidence that can verify combat service; and notice of the type of evidence that can show treatment or symptoms of PTSD in service. 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 generally Conway v. Principi, 353 F.3d 1369, 1375 (Fed. Cir. 2004) (holding that the rule of prejudicial error applies to cases involving VCAA notice requirements). Therefore, VA has met its obligations under all statutory and regulatory notice provisions. Furthermore, VA's duty to assist has also been met. The Veteran's VA treatment records have been obtained, showing mental health treatment from May 1988 to September 1992 at the VA Medical Center (VAMC) in Durham, North Carolina. A November 1992 psychological testing report completed at the Veteran's request is also of record. VA treatment records from the Durham VAMC are also available from the time the Veteran was reestablished as a patient in October 1999 to January 2008, but no additional mental health treatment is shown. Similarly, the May 2012 VA examination report mentions a PTSD screen in a March 2011 medical report, but describes the March 2011 report as pertaining to a "regular medical visit," not mental health treatment. The Veteran has consistently denied additional mental health treatment with VA. Therefore, all reports of VA mental health treatment are of record. See 38 U.S.C.A. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(3). VA has also completed all necessary steps to obtain the Veteran's private treatment records. See 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c)(1). In September 2007, the Veteran requested his treatment records from his private psychologist, dated from August 2007 to the present, and attached the necessary authorization and an August 2007 summary of treatment. An initial request and a follow-up request for these records were sent in November 2007 and August 2008, and, in response, the Veteran's private psychologist submitted statements dated January 2008 and September 2008. As two follow-up requests have been sent and a response has been obtained with no indication that subsequent requests will result in obtaining additional records of the Veteran's mental health treatment from his private psychologist, VA has no continuing obligation to undertake further efforts to obtain these records. No other relevant private treatment records have been identified by the Veteran. According the February 1993 rating decision, service treatment records dated from 1967 to 1979 were present in the claims folder at that time. Subsequently, a record of transfer dated June 1998 shows that service treatment records were transferred from the Records Management Center (RMC) to the Winston-Salem RO to be associated with the Veteran's existing claims folder, presumed to be located at the RO at that time. See VA Adjudication Procedures Manual, M21-1MR, pt. III, sbpt. iii, ch. 2, § A.4.e (Jan. 7, 2007) (hereinafter M21-1MR) (explaining that service records received by the RMC are forwarded to the RO in possession of the claims folder where one exists or has been established). However, a record of transfer dated from August 1998 shows that the Veteran's claims folder was not permanently transferred from the RMC to the Winston-Salem RO until two months after the service treatment records were sent to that location. Furthermore, folder management data from August 2007 shows that the service treatment records transferred in June 1998 were never consolidated with the Veteran's claims folder. M21-1MR, prt. III, sbpt. iii, ch. 2, § C.19.e-f. The RO requested a search for the Veteran's service treatment records at the RMC in August 2007, but they were not located. Accordingly, in the November 2007 notice letter, the Veteran was informed of alternative sources of evidence, including statements from persons who knew the Veteran in service, records and statement from service medical personnel, employment-related examination reports, medical evidence from hospitals, clinics, and physicians that treated the Veteran after separation, pharmacy prescription records, and/or insurance-related examination reports. See M21-1MR, pt. III, sbpt. iii, ch. 2, § E.27.b (listing the various types of evidence VA may use to supplement or as a substitute for service treatment records). In March 2012, the Veteran's service personnel file was obtained from the Department of Defense pursuant to the Board's October 2010 remand order. The Board therefore finds that further attempts to locate the Veteran's service treatment records, last seen in June 1998, would be futile as appropriate efforts to search for the Veteran's records have already been completed, and the Veteran has been asked to submit alternative sources of evidence. Further, in asking the Veteran to submit alternative sources of evidence, VA has met the heightened obligation to assist the claimant in developing the claim where service records are lost or missing through no fault of the Veteran. See Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005). Additionally, the Veteran has never claimed that he received mental health treatment in service, and his service personnel and other service records pertaining to stressor verification are present in the claims folder. Therefore, as no relevant service records are missing, no prejudice can result to the Veteran in adjudicating his claim for service connection for PTSD as the missing records would not have any impact on any issue of law or fact material to the issue on appeal. See 38 C.F.R. § 3.159(c)(3) (stating that VA will make efforts to obtain the Veteran's service medical records if relevant to the claim). 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. 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 critical 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 May 2012 VA examination report was provided by an appropriate medical professional, a Ph.D. neuropsychologist, following a complete review of the claims file and thorough examination and interview. The May 2012 examiner presented a clear factual foundation and reasoned basis for the conclusion reached. The Veteran alleges that the examiner exhibited bias against his claim and was overly reliant on psychological testing at the expense of examination by interview, but the examination report shows that the examiner recorded and fully considered the Veteran's responses to all interview questions, and used these answers, in combination with the available test data, to make the requested determination on the issue of the existence of PTSD. With regard to other possible diagnosis, as discussed further below, validity testing showed that the Veteran's self-reported data was unreliable. Therefore, as the Veteran has been provided with a thorough VA examination where his full relevant medical history, including his lay statements, was considered and a detailed rationale was provided, VA has fulfilled the duty to provide the Veteran with a VA examination. See 38 U.S.C.A. § 5103A(d); McLendon, 20 Vet. App. at 81; 38 C.F.R. § 3.159(c)(4). 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 October 2010 and May 2012 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Board directed the RO to provide the Veteran with a copy of the amended version of 38 C.F.R. § 3.304(f); to obtain additional information from the Veteran regarding his claimed stressors; to attempt to verify the in-service stressors asserted, and to provide the Veteran with a VA examination in order to obtain a determination of whether a diagnosis of PTSD is warranted under the DSM-IV criteria and an etiological opinion in consideration of the Veteran's claimed stressors and, in the alternative, in accordance with the criteria under the amended version of 38 C.F.R. § 3.304(f). Review of the record shows that the AMC provided the Veteran with the requested notice, requested the necessary information from the Veteran, completed all appropriate actions to verify his claimed stressors, and provided him with the requested VA examination. The Veteran's claim was readjudicated in an April 2012 Supplemental Statement of the Case (SSOC) and again, as directed in the May 2012 remand, in a November 2012 SSOC after the requested supplemental opinion was obtained from the May 2012 VA examiner. II. Service Connection The Veteran claims that he currently suffers from PTSD due to his traumatic experiences during his service in Vietnam. His claimed stressors of being subject to constant enemy fire while in the air and on base in Phan Rang, Vietnam, and in the air around his base in Ubon, Thailand, have been corroborated by independent credible evidence. See March 2012 PTSD Stressor Verification Review. 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). However, 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 the 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, 7 Vet. App. at 511; 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. In cases where, as here, the appellant's service treatment records have been lost or destroyed, the Board has a heightened obligation to provide well-reasoned findings and conclusions, to evaluate and discuss all of the evidence that may be favorable to the appellant, and to provide an adequate statement of the reasons or bases for its rejection of such evidence. Washington, 19 Vet. App. at 370-71. While there is a heightened duty to consider the applicability of the benefit-of-the-doubt rule where service records are missing, no presumption against VA lowering the legal standard for proving the Veteran's claim is raised. See Cromer, 19 Vet. App. at 218-19. Here, the preponderance of the evidence is against finding that the Veteran has a diagnosis of PTSD. The Veteran was initially provided with a VA examination with a VA psychologist in April 2011. The examiner reviewed the Veteran's medical history as documented in the claims folder and in his VA treatment records and conducted an examination including an interview and psychological testing. The examiner found that the criteria for a diagnosis of PTSD were not met because the Veteran was not able to provide specific examples of experiences that would be consistent with a diagnosis of PTSD. The examiner explained that while there was a genuine possibility that the Veteran may have some psychiatric disorder, any Axis I DSM-IV psychiatric diagnosis was deferred due to objective evidence of symptom amplification/exaggeration on the Structured Inventory of Malingered Symptomatology (SIMS), in addition the Veteran's vague and evasive style of responding during the interview. Specifically, during the interview, the Veteran would not directly respond to many of the questions asked and could not provide specific information about his current symptoms or social history. With regard to testing, the examiner explained that the SIMS test is a self-administered screening measure comprised of psychiatric and cognitive conditions that are not typical experiences of persons with actual psychiatric disorders or cognitive conditions. It provides a total score that is used for the detection of symptom exaggeration and endorsement of atypical symptom patterns across a variety of settings. The recommended cutoff score in the SIMS manual is 14 and above. The Veteran scored a 38, which, the examiner explained, means he endorsed a high frequency of symptoms that are highly atypical and inconsistent in patients with genuine psychiatric disorders. Consequently, the examiner did not interpret his other test results due to their presumed invalidity on the basis of the Veteran's SIMS score. In May 2012, the Board determined that further explanation was needed regarding the conclusion that the Veteran was not able to provide specific examples of experiences that would be consistent with a diagnosis of PTSD, particularly where the examination report showed that the Veteran described flying aircraft under fire in Vietnam, at times carrying body bags. Consequently, in May 2012, the Veteran was provided with a second VA examination with a second VA examiner, a clinical neuropsychologist. The May 2012 VA examiner also found that the psychological evidence did not establish a diagnosis of PTSD under the DSM-IV criteria. The examiner explained that the stressors reported by the Veteran were described in a vague and generalized manner and were thereby not adequate to support a diagnosis of PTSD. Furthermore, he explained that the Veteran's medical history indicated that he did not have PTSD. The examiner specifically listed negative PTSD screens in July 2004, June 2005, and March 2011; denial of PTSD symptoms in an August 1998 psychiatric evaluation; denial of any relevant symptoms on an October 1993 medical history report, including frequent trouble sleeping, depression or excessive worry, loss of memory, and nervous trouble; atypical test results on the Minnesota Multiphasic Personality Inventory (MMPI) in November 1992; a lack of indication of psychiatric distress during service on an August 1974 fitness report; continued atypical voluntary participation in activities related to the military, as opposed to avoidance of military stimuli; and the infrequency of any current treatment for PTSD. Further, the May 2012 VA examiner found that the data did not substantiate a diagnosis of any other mental disorder under the DSM-IV criteria as, once again, testing produced clear evidence of symptom amplification and exaggeration on multiple standardized measures. The examiner further determined that the Veteran's unwillingness to be forthright, combined with the repeated test evidence, indicates that this symptom amplification and exaggeration is intentional. As in April 2011, the Veteran's SIMS score of 29 was above the cutoff level of 14 suggested in the manual, as well as the most liberal suggested cutoff of 25. The examiner explained that while this score was lower than the April 2011 SIMS score, both scores indicated symptom amplification and exaggeration. Additionally, both the primary and secondary validity scales on the MMPI-2, described by the examiner as a longstanding, well-standardized, and well-regarded test of psychiatric symptoms, symptom validity, and personality factors, showed evidence of symptom amplification and exaggeration. Furthermore, the Veteran's scores on the MMPI-2's Variable Response Inconsistency (VRIN) and True Response Inconsistency (TRIN) scales were within normal limits, indicating that the evidence of symptom amplification and exaggeration was not the result of random responding or some other simplistic method of "spoofing" the results; rather, the Veteran was consistent in over-reporting his symptoms. Furthermore, the evidence of symptom amplification and exaggeration shown by the Veteran's scores on the MMPI-2's validity scales was corroborated by elevated primary clinical scale scores in all MMPI-2 clinical categories, as is typical of MMPI-2 primary scale profiles in situations where primary and secondary validity scale scores are elevated. All additional psychological tests administered (i.e. the Beck Depression Inventory (BDI-2), the Beck Anxiety Inventory (BAI), Center for Epidemiologic Studies Depression Scale (CES-D), and the Posttraumatic Stress Disorder Checklist - Military (PCL-M)) also showed improbably elevated scores, further corroborating the evidence of symptom amplification and exaggeration. Consequently, the primary clinical scale pattern on the MMPI-2 was rendered invalid and uninterpretable due to clearly demonstrated symptom amplification and exaggeration, as shown by the significantly elevated primary and secondary validity scores. The examiner explained that while it is certainly possible that the Veteran suffers from some non-service related Axis I disorder, such as substance abuse or dysthymia, or an Axis II personality disorder, any accurate and valid interpretation of the psychological testing procedures administered at the May 2012 VA examination was impossible without resorting to speculation due to the lack of valid clinical testing data such that a reliable diagnosis could not be provided. Conversely, the Veteran contends that the statements submitted by his treating psychologist show that he has a valid diagnosis of PTSD. In an August 2007 statement, the Veteran's private psychologist reported a diagnosis of chronic and severe PTSD under the DSM-IV criteria. This diagnosis was substantiated by the determinations that (1) the Veteran has a history of having experienced traumatic events involving the serious threat of injury to self and serious injury to and death of others; (2) he responded with fear, helplessness, and horror; (3) he reexperiences the traumatic events as distressing thoughts and dreams; (4) he avoids stimuli associated with the trauma and exhibits general numbing, shown by his avoidance of media concerned with military or war, conversations about his military experience, isolating behaviors and lack of social activities, and feelings of estrangement; (5) his increased arousal manifested by difficulty sleeping, irritability, hypervigilance, and exaggerated startle response; (6) the existence of symptoms lasting longer than one month; and (7) the existence of symptoms causing clinically significant impairment in his occupational, social, and personal life. Review of the remaining records shows inconsistent mental health treatment for variously reported symptoms and variously diagnosed conditions from June 1983 to the present. Treatment records from June 1983 and May 1988 show irregular treatment for symptoms of anxiety and depression. In August 1988, the Veteran was referred for a psychological evaluation for PTSD, depression, and/or a personality disorder. Clinical data from an MMPI completed at home, showing features of interpersonal distrust and excessive sensitivity as well as hostility and resentment, was atypical for PTSD, but not inconsistent with PTSD. Test data was determined to be valid and not indicative of excessive denial or exaggeration of difficulty. In an hour-long structured interview in September 1988, all three interviewers found that the Veteran met the diagnostic criteria for a past and present diagnosis of PTSD. As a result, the Veteran was given a diagnosis of PTSD for purposes of treatment. However, there is no record of additional psychiatric treatment until January 1992, when the Veteran was treated for a diagnosis of depression and a "history of PTSD." In July 1992, treatment records note that the Veteran's uneven treatment history and improbable responses regarding alcohol abuse raised some suspicion. Upon formal psychological testing in November 1992, the Veteran was found to suffer from symptoms of depression and anxiety, likely due to his history of excessive drinking, prolonged marital disharmony, and interpersonal problems, instead of PTSD. The report notes that the Veteran did not report war or combat trauma of such a nature or intensity that would generally be considered causative of PTSD, did not describe specific intrusive thoughts of reliving such trauma, and continued engagement in very activities alleged to be associated with his PTSD, instead of avoiding these stimuli. Consequently, it was determined to be unlikely that he suffered from PTSD. In November 1992, upon review of the psychological testing report, a VA examiner diagnosed the Veteran with a depressive disorder, not otherwise specified, and specifically found that a diagnosis of PTSD was not warranted. Where, as here, there is conflicting medical evidence 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. Specifically, 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 May 2012 VA examiner, supported by the earlier findings of the April 2011 VA examiner and November 1992 psychological testing data, outweigh the statements provided by the Veteran's treating psychologist and the September 1988 diagnosis of PTSD in the Veteran's VA treatment records. As explained by the May 2012 VA examiner, the diagnosis reported by the Veteran's private psychologist was given without the benefit of symptom validity or any other objective psychological testing. Consequently, the diagnosis she provided is of decreased probative value as the validity tests administered by the VA examiners indicate that relevant facts provided by the Veteran have been shown to be inaccurate. See Reonal, 5 Vet. App. at 461. Furthermore, in the opinion of the May 2012 VA examiner, the trauma stressors reported by the Veteran's private psychologist are both different in character than those reported to the VA examiner and insufficient to cause chronic, long-standing PTSD. As the May 2012 VA examiner, a Ph.D. neuropsychologist, has a greater degree of relevant expertise than the Veteran's private psychologist, a licensed psychological associate (LPA) with a master's degree who must work under the supervision of a fully licensed psychologist, he is more capable of reliably assessing the sufficiency of the Veteran's claimed stressors. The Veteran's private psychologist does not provide any rationale for her determination that the Veteran's claimed stressors are sufficiently specific to support a diagnosis of PTSD. Therefore, as the May 2012 VA examiner has a greater degree of relevant expertise and specifically disagreed with the Veteran's psychologist's characterization of the sufficiency of his reported stressors, and, furthermore, the Veteran's private psychologist was not aware of facts and data shown to be critical in providing an accurate diagnosis, the diagnosis of PTSD provided by the Veteran's private psychologist is outweighed by the more probative opinion of the May 2012 VA examiner. The September 1988 PTSD diagnosis was later rescinded in November 1992 as a result of additional psychological testing and evaluation following questions that were raised regarding the Veteran's irregular treatment history and improbable descriptions of his alcohol use. Therefore, the determination in November 1992 that a diagnosis of PTSD was not warranted was based on additional evidence and information that was not available at the time of the September 1988 PTSD diagnosis. Furthermore, that diagnosis was provided in spite of clinical MMPI results that were, as noted by the May 2012 VA examiner, atypical for PTSD. As there is a more complete and developed basis for the November 1992 finding than the September 1988 finding, particularly in light of the review of the medical history and additional test data provided by the May 2012 VA examiner, the preponderance of the Veteran's VA treatment records also weigh against finding that a diagnosis of PTSD is warranted. The Veteran has consistently reported that he has been diagnosed with PTSD and he is competent to report his diagnoses of PTSD. See Davidson, 581 F.3d at 1316. Furthermore, his assertions regarding his diagnosis and treatment for PTSD are corroborated by his private treatment records and are credible. See Caluza, 7 Vet. App. at 511. However, the diagnosis reported by the Veteran has been found to be outweighed by the medical evidence against finding a diagnosis of PTSD in the record, particularly the opinion provided by the May 2012 VA examiner. Therefore, his report of the same diagnosis is also outweighed. Contrary to the Veteran's assertions, the diagnosis offered by his private psychologist is not equally valid to the diagnosis provided by the May 2012 examiner simply because it is based on the same DSM-IV criteria. Here, the May 2012 VA examiner explicitly disagreed with his private psychologist's opinion regarding the sufficiency of the stressors reported by the Veteran to support a diagnosis of PTSD. As the May 2012 VA examiner has a greater degree of relevant expertise and explained the reasoning behind his opinion, his determination regarding the insufficiency of the stressors alleged is more probative than that of the Veteran's private physician. Consequently, the private psychologist's opinion is not equally valid to the opinion provided by the May 2012 VA examiner. The probative value of the VA examiner's opinion is much greater, and, accordingly, the Veteran's private psychologist's opinion is outweighed. Other possible psychiatric diagnoses have also been considered. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). 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. However, as explained by the May 2012 VA examiner, there is no conclusive evidence establishing a diagnosis of any other psychiatric disorder. The Veteran's private psychologist provided a diagnosis of a depressive disorder, not otherwise specified, in September 2008, but there is no supporting rationale for this finding. Conversely, previous medical evidence shows that the Veteran has not consistently tested positively for depressive symptoms, and the May 2012 VA examination data shows that any clinical testing data completed without corresponding test validity data cannot serve as a valid basis for any psychiatric diagnosis. Therefore, while the May 2012 VA examiner acknowledged that the Veteran might have a psychiatric disorder other than PTSD, no valid determination could be made due to the lack of valid test data. Furthermore, the May 2012 VA examiner also described any existing disorder as unrelated to the Veteran's military service, corresponding with the findings in the November 1992 psychological testing report. Therefore, the evidence does not support the existence of a specific psychological diagnosis other than PTSD, and, furthermore, even if a diagnosis could be made, any diagnosed psychiatric disorder would be less likely than not to be related to the Veteran's military service. 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, as the preponderance of the evidence is against finding that the Veteran has a properly diagnosed psychiatric disorder of PTSD, or any other psychiatric disorder other than PTSD, service connection for an acquired psychiatric disorder, to include PTSD, cannot be substantiated. See generally 38 C.F.R. §§ 3.303, 3.304(f), 4.125. Furthermore, as there is no diagnosis of PTSD or any other acquired psychiatric disorder, no psychiatric disorder can be linked to the Veteran's military service, irrespective of whether the occurrence of a stressor in service has been established. See 38 C.F.R. §§ 3.303; 3.304(f). Therefore, service connection for an acquired psychiatric disorder, to include PTSD, must be denied. As the preponderance of the evidence is against the claim, the evidence 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. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs