Citation Nr: 1301985 Decision Date: 01/17/13 Archive Date: 01/23/13 DOCKET NO. 99-18 585 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, to include chronic hiatal hernia, gastroesophageal reflux disease (GERD), gastritis, peptic ulcer, peptic ulcer disease, persistent reflux, and dyspepsia, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include major depressive disorder, depression, adjustment disorder, dysthymic disorder, and personality disorder, to include as secondary to service-connected PTSD. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). WITNESSES AT HEARINGS ON APPEAL The Veteran, his spouse, and B.B. ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran served on active duty from January 1970 to January 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2001 by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The Veteran, his spouse, and B.B. testified during hearings before RO personnel in October 1998 and January 2000. Transcripts of those hearings are of record. Also of record is a transcript of a September 2003 video-conference hearing in which the Veteran and his spouse testified before a Veterans Law Judge who has since left the Board. In a June 2009 letter, the Veteran was informed of that Veterans Law Judge's retirement and offered an opportunity for a new Board hearing. In response, the Veteran submitted a September 2009 statement affirming his desire for a hearing before a different Veterans Law Judge. Thereafter, in December 2009, the Veteran testified alone before the undersigned Veterans Law Judge, who was sitting at the North Little Rock RO. A transcript of that second Board hearing has been associated with the claims file. The Board observes that the issues listed on the title page of this decision were previously remanded in March 2004, July 2006, October 2009, and August 2011. As discussed in further detail below, the Board finds that there has been substantial compliance with its prior remand directives with respect to the Veteran's service connection claims. As such, appellate review of those issues may proceed. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Next, the Board acknowledges that the Veteran's service connection claims were initially limited to the underlying disabilities of hiatal hernia and major depressive disorder. Nevertheless, the record reflects complaints and clinical findings of multiple gastrointestinal and acquired psychiatric disorders, including hiatal hernia, GERD, and dyspepsia, as well as major depressive disorder, depression, adjustment disorder, and dysthymic disorder. In view of that lay and clinical evidence, which appears to expand the scope of the Veteran's pending service connection claims, the Board has recharacterized those issues as reflected on the title page. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (when determining the scope of an issue on appeal, the Board has an obligation to broadly construe the claimant's description of the claim, the symptoms he describes, and the information he provides in connection with that claim); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As a final introductory matter, the Board notes that a claim for entitlement to a rating in excess of 70 percent for PTSD was previously raised by the Veteran in an August 2009 written statement. The Board, in its most recent remand in August 2011, referred that claim to the agency of original jurisdiction (AOJ) for initial adjudication. However, it does not appear that the AOJ has done so as of yet. Accordingly, the Veteran's claim for a higher PTSD rating is again referred to the AOJ for appropriate action. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran's currently diagnosed gastrointestinal disorders are not shown to be causally or etiologically related to any disease, injury, or incident in service, a peptic ulcer did not manifest within one year of service discharge, and were not caused or aggravated by his service-connected PTSD. 2. The Veteran's currently diagnosed depression, which has been clinically distinguished from his PTSD, is not shown to be causally or etiologically related to any disease, injury, or incident in service, psychosis did not manifest within one year of service discharge, and was not caused or aggravated by his service-connected PTSD. Moreover, the records reflects that the Veteran's other psychiatric symptoms are contemplated in his current 70 percent disability rating for PTSD, which is not at issue in this appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for a gastrointestinal disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. The criteria for service connection for an acquired psychiatric disorder other than PTSD have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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 of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Here, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, VCAA letters dated in July 2004, August 2006, October 2008, and January 2009 informed the Veteran of what evidence was required to substantiate his service connection claims on a direct basis and of his and VA's respective duties for obtaining evidence. The AOJ also provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. With respect to the secondary aspect of the Veteran's service connection claims, the Board notes that the above VCAA notice letters failed to address such a theory of entitlement. This being the case, the VCAA notice as relevant to the secondary aspect of the Veteran's claims was defective. Significantly, however, this due process deficiency was remedied in a subsequent VCAA notice, which was sent to the Veteran in September 2011 in compliance with the Board's latest remand. See Stegall v. West, 11 Vet. App. 268 (1998). The Board recognizes that the above VCAA notice letters were issued after the initial September 2001 rating decision denying the Veteran's claims. Nevertheless, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claim following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). Moreover, the Court has clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claim. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after all of the above notice letters were issued, the Veteran's service connection claims were readjudicated in an August 2012 supplemental statement of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Next, relevant to the duty to assist, the Veteran's service treatment and personnel records, as well as his pertinent VA treatment records, have been obtained and considered. Additionally, VA has obtained copies of Social Security Administration (SSA) records showing that the Veteran has been awarded SSA benefits based upon service-connected and nonservice-connected disabilities. Significantly, the Veteran has not identified, and the record does not otherwise suggest, the existence of any outstanding SSA records that have bearing on his current claims for service connection. Accordingly, VA need not attempt to obtain any other SSA records with respect to those claims. Golz v. Shinseki, 590 F.3d 1317, 1323 (2010). The Board recognizes that the Veteran has identified potentially pertinent records concerning his prior participation in VA's vocational rehabilitation program. However, while the Board previously remanded the Veteran's case in an effort to obtain his complete VA Vocational Rehabilitation and Education file, the AOJ has since issued a formal finding of unavailability with respect to that file in accordance with 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). See Formal Finding of Records Unavailability, dated November 18, 2011. Moreover, the Board notes that, after receiving notification of the unavailability of his VA Vocational Rehabilitation and Education file, the Veteran himself has submitted copies of vocational rehabilitation records that are within his possession. As such, the Board finds that sufficient efforts to obtain the Veteran's vocational rehabilitation records have been made and that an additional remand to obtain such records would serve no useful purpose. Significantly, the Veteran has not identified any additional, outstanding records that have not been requested or obtained. Therefore, the Board finds that VA has satisfied its duty to assist in obtaining all available records. Next, the Board is cognizant that the duty to assist includes the duty to provide a medical examination or obtain a medical opinion where necessary to make a decision on the claim. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, in accordance with the Board's latest remand, the Veteran was afforded a series of VA examinations in October 2011, which yielded medical opinions relevant to his service connection claims. Those medical opinions considered all of the pertinent evidence of record, including the Veteran's own statements, and were supported by detailed rationales, relying on and citing to the records reviewed. Significantly, the Veteran has not contended that any of these examinations was inadequate for rating purposes. Nor does the record otherwise suggest that these examinations, in tandem with the other pertinent evidence of record, have been insufficient to adjudicate his service connection claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes an examination, even if not required to do so, an adequate one must be produced). As such, the Board considers it unnecessary to remand for additional VA examinations in connection with the issues decided herein. As a final point regarding VA's duty to assist, the Board observes that the Veteran was provided opportunities to testify in support of his service connection claims at multiple Board and Decision Review Office (DRO) hearings. In this regard, the Board acknowledges that, in its recent decision in Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) imposes on a VA hearing officer (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. See 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board finds that the RO hearing officers and the Veterans Law Judges who presided over the Veteran's hearings articulated the issues on appeal, asked questions relevant to the etiology of his claimed gastrointestinal and acquired psychiatric disorders, and solicited testimony regarding any outstanding evidence. Moreover, there is no indication that the Veteran was otherwise denied due process during the course of his Board and DRO hearings. Further, the Board considers it significant that, throughout the pendency of this appeal, the Veteran has displayed actual knowledge of the bases of the prior adjudications and the elements that were lacking to substantiate his claims for service connection. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Thus, even presuming, without conceding, that one or more of the Veteran's hearings did not fully comply with the Bryant provisions, such error was harmless in light of his actual knowledge of these provisions, in tandem with the subsequent readjudication of his appeal. See Prickett v. Nicholson, 20 Vet. App. 370 (2006) (indicating that actual notice and readjudication is sufficient to cure any notice error). In light of the foregoing, the Board finds that the AOJ has substantially complied with the prior remand directives such that no further action is necessary in this regard. See D'Aries, supra. Moreover, the Board finds that VA has fully satisfied the duty to assist in this instance. Indeed, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis In hearing testimony and other documents of record, the Veteran contends that his service-connected PTSD caused or permanently worsened his currently diagnosed gastrointestinal and acquired psychiatric disorders. As such, he asserts that service connection is also warranted for those disorders. In light of the Veteran's contentions, the Board will consider whether to grant service connection for any currently diagnosed gastrointestinal or acquired psychiatric as secondary to his PTSD. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (holding that the Board is required to weigh all theories of entitlement raised either by the claimant or by the evidence of record as part of the non-adversarial administrative adjudication process). Moreover, while mindful that the Veteran has not raised a claim for direct service connection in this case, the Board will also consider that theory of entitlement in order to fully assess the merits of his appeal. See Hodge v. West, 155 F.3d 1356, 1362-1363 (Fed. Cir. 1998) (noting that Congress expects the VA 'to fully and sympathetically develop a Veteran's appeal to its optimum before deciding it on the merits'). In addition, the Board will consider whether any of the disorders at issue fall within the category of chronic diseases for which service connection may be granted on a presumptive basis. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; evidence of in-service incurrence or aggravation of a disease or injury; and evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. When, as in the instant case, a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including peptic ulcers and psychosis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.384, the term "psychosis" is defined so as to include brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board now turns to the pertinent lay and clinical evidence underlying the Veteran's claims. See Dela Cruz v. Principi, 15 Vet. App. 143 (2001) (discussion of all evidence by the Board is not required when the Board has supported its decision with thorough reasons and bases regarding the relevant evidence). The Veteran's service treatment records, including the reports of his December 1969 pre-enlistment and January 1972 separation examinations, are negative for any complaints or clinical findings of gastrointestinal or psychiatric problems. Thus, absent any other showing of chronic in-service disability relevant to the issues on appeal, the Board finds that the overall record does not support a finding of chronicity in service. Accordingly, the Board must now consider whether the record supports a finding of continuity of symptomatology sufficient to grant the Veteran's claims. In this regard, the Board notes that, under 38 C.F.R. § 3.303(b), such a showing of continuity of symptomatology may, by itself, satisfy the elements of in-service incurrence or aggravation and nexus in a claim for service connection for a currently diagnosed disorder. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Significantly, in this case, the Veteran has not expressly argued that the symptoms underlying his gastrointestinal and non-PTSD acquired psychiatric disorders have persisted on a continuous basis since service. Nor does the record otherwise reveal such a showing of continuity of symptomatology. On the contrary, the Board notes that the earliest evidence of treatment for gastrointestinal and mental health problems is dated in the mid-1990s. Specifically, the Veteran's VA medical records reflect that, in December 1995, he sought outpatient treatment for a history of peptic ulcer disease. Although contemporaneous X-rays of the Veteran's upper gastrointestinal tract were devoid of clinical abnormalities, he was prescribed Zantac for his subjective symptoms. The record thereafter shows that the Veteran continued to undergo periodic treatment for gastrointestinal complaints, which were alternately diagnosed as GERD; dyspepsia, secondary to nonsteroidal anti-inflammatory drugs prescribed for his back problems; gastritis; peptic ulcer disease; and persistent reflux. Although the Veteran declined surgery for these problems, he did submit to diagnostic testing in the form of a January 2010 esophagogastroduodenoscopy, which uncovered stomach polyps but was negative for cancer. The Veteran also underwent an April 2011 dysphagia study, which revealed a normal swallowing pattern. Significantly, neither of these procedures yielded definitive results with respect to the etiology of the Veteran's gastrointestinal symptoms. Moreover, none of the VA treatment that the Veteran received for those symptoms suggested a link to his service-connected PTSD or a direct onset in service. Further, while the Veteran's complaints of chest pains were initially attributed to his reflux disease, those complaints were later found to be characteristic of a different disorder (coronary artery disease) for which service connection was established in the August 2011 Board decision. Concurrent with the above VA medical records, reflecting complaints and clinical findings of gastrointestinal disorders, are mental health records showing ongoing outpatient treatment for psychiatric problems. Those records reflect that, on at least four occasions since the mid-1990s, the Veteran has been hospitalized for suicide attempts. Moreover, while the vast majority of those records attribute the Veteran's psychiatric problems to his service-connected PTSD, they also contain diagnoses of other mental disorders, including major depressive disorder, dysthymic disorder, adjustment disorder, situational reaction, and cyclothymia. In addition to the above VA outpatient and hospitalization records, the claims file contains reports of private psychiatric testing, which the Veteran underwent in the late 1990s in connection with his pursuit of vocational rehabilitation benefits. Those reports, which the Veteran himself has submitted in support of his claim, are replete with documented symptoms of depression, anxiety, and flashbacks. The Board notes that such symptoms have been found to support diagnoses not only of PTSD and depression but also of personality disorder. However, with the exception of PTSD, those diagnoses have not been clinically linked to the Veteran's service. The above records are illustrative of the complex nature and etiology of the disorders for which the Veteran is claiming service connection. Such complexity led the Board, in its most recent remand, to request VA medical examinations in connection with his claims. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c). Thereafter, the Veteran was afforded a VA esophagus and hiatal hernia examination, conducted within the context of a broader general examination, and a VA mental disorders (other than PTSD) examination. Each examination was administered in October 2011 and included an in-depth interview of the Veteran, a clinical evaluation, and a review of the claims file. However, neither of the clinicians who conducted those examinations had access to the Veteran's vocational rehabilitation records as such records were not associated with the claims file until later in the appeals period. Based upon his clinical examination and records review, the VA esophagus and hiatal hernia examiner determined that, while the Veteran's current symptoms supported diagnoses of GERD and dyspepsia, he did not meet the criteria for hiatal hernias or other gastrointestinal disorders. Moreover, the examiner concluded that the gastrointestinal symptoms, which the Veteran currently displayed or were otherwise of record, were unrelated to his service-connected PTSD. In this regard, the examiner noted that he "kn[ew] of no objective medical data" that suggested a nexus, either on the basis of causation or aggravation, between the gastrointestinal problems exhibited by the Veteran and his service-connected PTSD. The examiner further noted that he "could not find documentation of gastroesophageal reflux disease while in the service or any type of medical condition similar to that." Consequently, that examiner concluded that the Veteran's current gastrointestinal problems were in no way service-related. The VA mental disorder examiner reached a similar conclusion with respect to the Veteran's "symptoms of depression," which the examiner found did not rise to the level of a diagnosed mental disorder. See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) criteria. The examiner further indicated that such symptoms, regardless of diagnosis, could not be related to the Veteran's PTSD but were rather attributable to a variety of nonservice factors, including his concerns over his finances, family members' deaths, and age-related physical problems. Conversely, the examiner opined that all of the other mental health symptoms, which the Veteran currently exhibited or were otherwise of record, were part and parcel of his PTSD, irrespective of how such symptoms had been previously diagnosed. Moreover, that examiner found no evidence of an acquired psychiatric disorder, distinguishable from the Veteran's PTSD, which was caused or aggravated by that condition or otherwise related to his active service. In assessing the probative value of the above examiners' opinions, the Board acknowledges that neither reviewed the vocational rehabilitation records that the Veteran later submitted in connection with his appeal. As noted previously, those vocational rehabilitation records show that the Veteran underwent psychological testing in the late 1990s, which yielded diagnoses of PTSD and other mental disorders, including depression and personality disorder. However, none of the mental health specialists who conducted that prior testing attributed any of the Veteran's non-PTSD conditions to his military service. Therefore, the Board considers those specialists' prior assessments to be consistent with the overall findings of the October 2011 VA mental disorder examiner. Moreover, there is nothing in the record that otherwise contradicts the findings of either October 2011 VA examiner with respect to the etiology of the Veteran's gastrointestinal and psychiatric symptoms. In this respect, the Board acknowledges that both October 2011 examiners collectively determined that the Veteran's current symptoms did not warrant all of the various diagnoses noted in his claims file. Nevertheless, the Board observes that those examiners' core findings - with respect to a lack of nexus between the Veteran's underlying gastrointestinal and psychiatric symptoms, regardless of diagnosis, and his active service, including his service-connected PTSD - are uncontroverted by the record. Such consistency with the other evidence of record adds to the probative weight of those examiners' opinions. 38 C.F.R. § 4.1; Prejean v. West, 13 Vet. App. 444 (2000);Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). Additionally, the Board considers it significant that both October 2011 VA examiners appear to have based their opinions on sound medical principles and supported their findings with detailed rationales. Prejean, 13 Vet. App. at 448-9 (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion); see also Sklar v. Brown, 5 Vet. App. 140, 146 (1993) (probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion); Nieves-Rodriguez v. Peak, 22 Vet. App. 295, 299-301 (2008) ('the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches.') quoting Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also, Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ('[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.'). As such, the Board accepts those VA examiners' opinions as being highly probative with respect to the Veteran's claims. See Guerrieri v. Brown, 4 Vet. App. 467 (1993); Gabrielson v. Brown, 7 Vet. App. 36 (1994) (noting that the credibility and weight to be attached to medical opinions are within the province of the Board as adjudicator). After careful consideration of the above evidence, the Board finds that service connection for a gastrointestinal or an acquired psychiatric disorder is not warranted on a secondary basis. In this regard, the Board notes that the October 2011 VA esophagus and hiatal hernia examiner - whose opinion, for the foregoing reasons, is considered probative - found no evidence of a nexus between the Veteran's current gastrointestinal ailments and his service-connected PTSD. Nor did that examiner suggest a link between those ailments and any other service-connected disability. Moreover, while cognizant that other VA clinicians initially associated the Veteran's dyspepsia with his history of chest pains, the Board notes that those symptoms were later attributed to his coronary artery disease, a condition for which he is now service connected and which is no longer on appeal. Significantly, the Veteran has not contended, and the record does not otherwise suggest, that his coronary artery disease in any way caused or aggravated his dyspepsia or other gastrointestinal ailments. Furthermore, while the Veteran's aforementioned VA treatment notes indicate that his dyspepsia is secondary to his use of nonsteroidal anti-inflammatory drugs, the record reflects that such medication was prescribed for his low back problems for which he is not service-connected. Accordingly, the Board finds insufficient evidence to support a grant of service connection for any gastrointestinal disorder as secondary to the Veteran's PTSD or to any other service-connected disability. Similarly, there is nothing in the record that supports entitlement to service connection for an acquired psychiatric disorder on a secondary basis. As previously discussed, the October 2011 VA mental disorder examiner, whose opinion the Board deems probative, conducted a thorough review of the claims file, which included the various psychiatric diagnoses summarized above. Nevertheless, that examiner expressly determined, after weighing his own clinical findings against the other evidence of record, that the Veteran's psychiatric symptoms did not support a diagnosis of any DSM-IV disorder apart from his already service-connected PTSD. Moreover, despite finding that the Veteran currently displayed symptoms of depression independent of PTSD, that examiner determined that such symptoms were insufficient to warrant a clinical diagnosis under the DSM-IV. In this regard, the Board observes that a threshold requirement for service connection is evidence of currently diagnosed disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed). Accordingly, absent probative evidence of a current psychiatric disorder other than PTSD, an additional award of service connection cannot be made in this instance. However, even if the Board were to find that the Veteran did have a current diagnosis of depression, the record would still not support a grant of his service connection claim. Indeed, not only did the above VA mental disorder examiner clinically distinguish the Veteran's depression symptoms from his PTSD, that examiner further opined that there was no causal relationship between those underlying symptoms and that service-connected disability. Thus, even assuming that the Veteran meets the DSM-IV criteria for depression, the Board has no basis to grant service connection for that disorder as secondary to his PTSD. Nor does the Board have any basis to grant service connection for any other acquired psychiatric disorder under a secondary theory of entitlement. That is because the above examiner determined that all of the Veteran's other psychiatric symptoms, however previously diagnosed, were clinically indistinguishable from his PTSD. The VA examiner's findings as to etiology are uncontroverted by the other clinical evidence of record. As such, the Board has no basis to distinguish the Veteran's non-depression psychiatric symptoms from the PTSD for which service connection is already in effect. See Mittleider v. West, 11 Vet. App. 181 (1998) (finding that when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the Veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition). See also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). In reaching these conclusions, the Board is mindful that the VA mental disorders examiner did not consider the various psychiatric assessments contained in the Veteran's vocational rehabilitation records. As previously noted, those assessments yielded a clinical finding of personality disorder, which was not previously of record. Significantly, however, the Board notes that such a disorder does not qualify as a disease or injury under VA regulations. As such, it is not a disability for which service connection can be granted. 38 C.F.R. § 3.303(c) (2012). Moreover, while service connection may be warranted if an acquired psychiatric disorder was incurred or aggravated in service and superimposes upon a preexisting personality disorder, there is nothing in the record which supports such a finding in the instant case. 38 C.F.R. §§ 4.9; 4.125(a), 4.127 (2012); Carpenter v. Brown, 8 Vet. App, 240 (1995); Beno v. Principi, 3 Vet. App. 439 (1992). Furthermore, the Board observes that, with respect to the other psychiatric diagnoses listed in the Veteran's vocational rehabilitation records - PTSD and depression - such disorders were documented elsewhere in the record at the time of the October 2011 VA examination. As such, those disorders were presumably noted by the examiner in his review of the Veteran's claims file. See Marsh v. Nicholson, 19 Vet. App. 381 (2005) (noting the presumption of regularity that VA physicians and other government officials perform their duties correctly, fairly, in good faith, and in accordance with law and governing regulations). In any event, as discussed above, there is nothing in the Veteran's previously unobtained vocational rehabilitation records that contradicts the October 2011 VA examiner's conclusions with respect to the etiology of the Veteran's psychiatric problems. As such, those records may not serve as a basis for undermining that VA examiner's negative nexus opinion with respect to the Veteran's acquired psychiatric claim. Accordingly, the Board finds that the competent and credible evidence of record does not support a grant of service connection for either a gastrointestinal or an acquired psychiatric disorder under a secondary theory of entitlement. In this regard, the Board acknowledges that the Veteran himself has opined that he suffers from both gastrointestinal and acquired psychiatric disorders that are attributable to his service-connected PTSD. The Board has considered those lay assertions. While a lay person, the Veteran is certainly competent to offer evidence about his current gastrointestinal and psychiatric symptoms, such as abdominal distress and feelings of sadness and anxiety, which fall within the realm of his personal experience. See Layno v. Brown, 6 Vet. App. 465, 471 (1994). Significantly, however, the Veteran has not demonstrated that he has the requisite clinical expertise to opine as to medical etiology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Grover v. West, 12 Vet. App. 109 (1999); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Veteran's statements, standing alone, are insufficient to address a medically complex question, such as the link, if any, which exists between any of his current gastrointestinal and acquired psychiatric disorders and his PTSD. Accordingly, even after careful consideration of those lay statements, the Board finds service connection is not warranted on a secondary basis. Nor is service connection warranted on a direct basis. Indeed, neither of the October 2011 clinicians who examined the Veteran found any evidence of a gastrointestinal or acquired psychiatric disorder, other than PTSD, which was caused or aggravated in service. Also, the Veteran himself has not contended, and the record does not otherwise show, a continuity of symptomatology in connection with his gastrointestinal and acquired psychiatric disorder claims. On the contrary, the earliest evidence of treatment for such disorders is dated in the mid-1990s, more than two decades after he left the military. In this regard, the Board observes that, while the operative inquiry is whether there is a continuity of symptoms since the incurrence of a claimed injury or disease in service, rather than with a continuity of treatment, the lack of such evidence weighs against the Veteran's claims. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, while cognizant of the December 1995 VA treatment note referencing the Veteran's prior history of peptic disease, there is no indication that any earlier manifestation of that disorder had its onset in service or within the one-year presumptive period contemplated under 38 C.F.R. § 3.307 and 38 C.F.R. § 3.309. As such, service connection for that particular gastrointestinal disorder cannot be granted on either a direct or a presumptive basis. 38 U.S.C.A. §§ 1101, 1133 (West 2002) 38 C.F.R. §§ 3.303, 3.307 3.309 (2012). Furthermore, there is no basis for awarding service connection for any other gastrointestinal or acquired psychiatric disorder based upon the evidence presented herein. As a final point of analysis with respect to the Veteran's acquired psychiatric disorder claim, the Board wishes to emphasize that the PTSD for which he is already service connected has been rated 70 percent disabling under Diagnostic Code 9411. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). That particular diagnostic code subscribes to the criteria set forth in the General Rating Formula for Mental Disorders, which is used to rate all psychiatric disabilities, with the exception of eating disorders. As such, while cognizant of the fact that the Veteran has been assessed with multiple mental disorders other than PTSD, the Board nevertheless finds that his underlying psychiatric symptoms are collectively contemplated by the rating assigned for that disability. As noted in the Introduction, the Board is aware that the Veteran now seeks a higher disability rating for his PTSD and has referred that claim to the AOJ for adjudication. In the meantime, however, for VA to establish service connection for a different mental disorder and then assign a separate rating based upon the same symptomatology considered within the Veteran's PTSD award would amount to impermissible pyramiding. 38 C.F.R. §§ 4.414, 4.130, Diagnostic Codes 9201-9440 (2012). Thus, the Veteran would be effectively barred from receiving additional compensation for the other mental disorder even if service connection for such disability were granted. For the foregoing reasons, the Board finds that the record does not support a grant of VA disability benefits for any of the Veteran's actual or claimed gastrointestinal or non-PTSD acquired psychiatric disorders. In rendering this determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for the disorders listed above. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. In closing, the Board emphasizes that it is sympathetic to Veteran's contentions and does not in any way wish to diminish his decorated combat service in Vietnam. Nevertheless, the Board is precluded from granting his claims on an equitable basis and is constrained to follow the specific applicable provisions of law. 38 U.S.C.A. § 7104(c). ORDER Service connection for a gastrointestinal disorder, to include chronic hiatal hernia, GERD, gastritis, peptic ulcer disease, persistent reflux, and dyspepsia, to include as secondary to service-connected PTSD, is denied. Service connection for an acquired psychiatric disorder other than PTSD, to include major depressive disorder, depression, adjustment disorder, dysthymic disorder, and personality disorder, to include secondary to PTSD, is denied. REMAND Although the Board regrets the additional delay in this long-pending claim, a remand of the Veteran's TDIU claim is necessary to ensure that due process is followed and that there is a complete record upon which to decide that claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Throughout the pendency of this appeal, the Veteran has argued that he is incapable of obtaining or maintaining gainful employment due to his service-connected disabilities. As such, he contends that a TDIU is warranted. Total disability will be considered to exist where there is impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The issue of unemployability must be determined without regard to the advancing age of the Veteran. 38 C.F.R. §§ 3.341(a); 4.19. Factors to be considered are the Veteran's education, employment history, and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). In addition to the aforementioned disability of PTSD, rated as 70 percent disabling, the Veteran is currently service connected for coronary artery disease, rated as 60 percent disabling, and for residuals of tonsillitis and cervical adenopathy, rated as noncompensably disabling. His total combined disability rating is 90 percent. Thus, he meets the percentage criteria for a consideration for a TDIU. 38 C.F.R. § 4.16(a). Accordingly, the pertinent question is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. To answer that question, the Board must consider whether such disabilities, either singularly or jointly, render him unemployable. In this regard, the Board finds that an additional VA medical opinion would be helpful. The Board recognizes that, pursuant to its prior remand, the Veteran was afforded a series of October 2011 VA examinations, which addressed the impact of his service-connected disabilities on his employability. Specifically, a October 2011 VA general medical examiner opined that the Veteran's heart disease, cervical adenopathy, and tonsillitis, did not render him completely unemployable, but added that he would only be capable of performing "some type of sedentary job." Similarly, the October 2011 VA mental disorders examiner opined that the Veteran's psychiatric symptoms would not preclude all forms of employment. However, neither examiner offered a comprehensive opinion as to the occupational impact of the Veteran's service-connected disabilities in total. On the contrary, the VA general medical examiner focused only on the Veteran's service-connected physical disabilities while the VA mental disorders examiner limited her findings to his PTSD. Moreover, the Board notes that, while the general medical examiner did reference the Veteran's heart disease, service connection for that particular disability was not in effect at the time the examination was conducted. As such, the general medical examiner did not have the benefit of reviewing the RO's decision granting service connection and the complete record upon which that award was based. This reduces the probative value of that examiner's assessment. 38 C.F.R. § 4.1 (to ensure a thorough examination and evaluation, the Veteran's disability must be viewed in relation to its history). Additionally, the Board considers it significant that neither of the October 2011 VA examiners took into account the Veteran's vocational rehabilitation records, which were entered into evidence after the examinations took place. Those records, as previously noted, reflect that the Veteran underwent extensive psychological testing in the late 1990s, which assessed the impact of his PTSD and related mental health symptoms on his occupational and social functioning. Significantly, two of the examining clinicians (a licensed psychological examiner and a psychologist) opined in June 1998 that the Veteran's mental disorders, then characterized as major depressive disorder and dysthymic disorder, would not preclude him from undertaking "skilled low demand employment," but only if the "extensive vocational and personal guidance and assistance" were provided. In addition, a contemporaneously dated general medical assessment report, rendered in connection with an insurance claim and thereafter associated with the Veteran's vocational rehabilitation records, shows that he was diagnosed with cervical and lumbar spine disorders, coronary artery disease, dysthymia, and a personality disorder. Significantly, the physician who conducted that June 1998 examination determined that those conditions would have a permanent impact on the Veteran's ability to work. However, neither he nor the aforementioned licensed psychological examiner and psychologist provided rationales in support of their findings. Sklar, supra. For this reason, and because none of above clinicians provided a comprehensive assessment of the occupational limitations posed by those disabilities for which the Veteran is currently service connected, their opinions, standing alone, cannot serve as a basis for awarding TDIU. Moreover, while mindful of the records from the SSA, indicating that the Veteran was granted disability benefits as of March 1996 based on a primary diagnosis of degenerative disc disease, the Board observes that this award was predicated, in part, on a disorder of the lumbar spine for which he is not service-connected. As such, it also cannot serve as a stand-alone basis for awarding TDIU. Even if the SSA assessment were wholly favorable to the Veteran's TDIU claim, the Board would not consider that opinion sufficient to automatically grant the benefits sought on appeal. Indeed, while SSA findings, in general, constitute probative evidence with respect to a TDIU claim, they are not dispositive or altogether binding on VA since the agencies have different disability requirements. Collier v. Derwinski, 1 Vet. App. 413 (1991). In light of the foregoing deficiencies with the October 2011 VA examiners' findings and the other opinion evidence submitted in connection with the Veteran's TDIU claim, the Board finds that another VA opinion is needed to resolve this issue. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination or opinion for a disability benefits claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Accordingly, the Board finds that, on remand, the AOJ should obtain a VA addendum opinion that addresses the occupational effects of the Veteran's service-connected disorders, both singularly and jointly, on his ability to obtain and maintain gainful employment. Friscia v. Brown, 7 Vet. App. 294 (1995) (VA has a duty to supplement the record by obtaining an examination that includes an opinion as to the effect of the Veteran's service-connected disabilities on his ability to secure or follow a substantially gainful occupation). That VA addendum opinion should be supported by a detailed and comprehensive rationale that reconciles the previously obtained opinion evidence regarding the Veteran's employability and the other pertinent evidence of record. In addition, that opinion should be conducted by a licensed medical doctor in order to fully and fairly assess the merits of the Veteran's TDIU claim. Black v. Brown, 10 Vet. App. 297 (1997) (an opinion rendered by a clinician with specialized training may be considered more probative than a non-specialist's finding). Accordingly, the case is REMANDED to the RO for the following actions: 1. Forward the Veteran's claims file to a licensed medical doctor for an opinion regarding the impact of his service-connected disabilities (PTSD, coronary artery disease, cervical adenopathy, and tonsillitis) on his ability to obtain and maintain gainful employment. The claims file should be reviewed by the examiner in its entirety, and the examination report should reflect that review. The examiner should provide a rationale for any opinion expressed and reconcile it with all pertinent evidence of record. In particular, the examiner should address the Veteran's service and post-service medical records; his vocational rehabilitation records, to specifically include the employability findings rendered by the June 1998 psychology and general medical examiners; the opinions rendered by the October 2011 VA general medical and mental disorder examiners with respect to employment; and the SSA records showing that the Veteran has been awarded disability compensation due to service and nonservcie-connected disabilities. Specifically, the examiner should opine as to whether it is at least as likely as not that the Veteran's service-connected disabilities, either singularly or jointly, but without consideration of any nonservice-connected conditions and irrespective of his age, render him unable to secure or follow a substantially gainful occupation. The rationale for any opinion offered should be provided. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs