Citation Nr: 1304080 Decision Date: 02/05/13 Archive Date: 02/08/13 DOCKET NO. 08-17 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for psychiatric disability to include post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for right wrist disability including as secondary to service-connected residuals of fracture of the second right metacarpal. 3. Entitlement to service connection for right upper arm disability including as secondary to service-connected residuals of fracture of the second right metacarpal. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from November 1984 to July 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. Jurisdiction over the claims file has been transferred to the RO in Reno, Nevada. In May 2011, the Veteran provided testimony before the undersigned Veterans Law Judge at a Travel Board hearing held at the RO in Las Vegas, Nevada. A transcript of the hearing is associated with the claims files. In an October 2011 decision, the Board remanded these issues for additional development. The Board notes that the record indicates that the Veteran has been diagnosed with a number of psychiatric disorders by various health care providers, including PTSD, depression, bipolar disorder, affective disorder and personality disorder. The Board acknowledges 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. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board will accordingly consider entitlement to service connection for any and all psychiatric disorders, to include PTSD. The issues of entitlement to service connection for a right wrist disability and a right upper arm disability, both including as secondary to service-connected residuals of fracture of the second right metacarpal, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran has not reported consistently the in-service stressors which, in his view, led him to develop a psychiatric disability, to include PTSD, after service. 2. The competent evidence does not contain a diagnosis of PTSD based on a corroborated in-service stressor. 3. The Veteran's acquired psychiatric disorder, including anxiety disorder not otherwise specified (NOS), was not shown during service or for many years thereafter, and is not otherwise related to his active period of military service. CONCLUSION OF LAW A psychiatric disorder, to include PTSD was not incurred in or aggravated by active service, and may not be presumed to have been incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1111, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). 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 evidence 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 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper 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. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In addition, under 38 C.F.R. § 3.304(f) (3), VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. The RO provided notice to the Veteran in a November 2008 letter, prior to the date of the issuance of the appealed February 2009 rating decision. The November 2008 letter explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, in a March 2011 letter, the Veteran was asked to provide additional information concerning his alleged in-service assaults and he informed that he could submit alternative sources of information such as police reports, medical reports, and statements from other individuals who may have discussed his alleged incidents with. In light of the foregoing, the Board concludes that VA has satisfied the duties to notify the Veteran in the evidence necessary to substantiate his claim. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of service, VA treatment records and the reports of October 2010 and November 2011 VA examinations. The examination reports reflect that the VA examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate evaluation of the Veteran, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. As such, the Board finds that the October 2010 and November 2011 VA examination reports are sufficient upon which to base a decision with regard to this claim. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Also of record and considered in connection with the appeal are the various written statements provided by the Veteran and by the Veteran's representative on his behalf which include the Veteran's May 2011 hearing testimony. The Board finds that no additional RO action to further develop the record on the claim is warranted. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Claim for Service Connection for an Acquired Psychiatric Disorder Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see 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); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted at entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. 38 U.S.C.A. § 1111. To rebut the presumption of sound condition upon entry into service under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d. 1089 (Fed. Cir. 2004). To satisfy the second requirement for rebutting the presumption of soundness, the government must show, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with § 4.125(a) (i.e., Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)), (2) a link, established by medical evidence, between current PTSD symptoms and an in-service stressor, and (3) credible supporting evidence that the claimed in-service stressor occurred. As noted above, the Veteran asserts that he has PTSD due to noncombat-related stressors; specifically, that fellow soldiers attempted to sexually assault him on multiple occasions. Cases involving allegations of a personal assault fall within the category of situations in which it is not unusual for there to be an absence of service records documenting the events of which the Veteran complains. See, e.g., Patton v. West, 12 Vet. App. 272, 281 (1999). As noted under Paragraph 5.14(d), Part III, of VA's Adjudication Procedure Manual, M21-1, personal assault is an event of human design that threatens or inflicts harm. Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking. Id. Service records may not contain evidence of personal assault, and alternative sources, including testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, may provide credible evidence of an in-service stressor premised on personal assault. See YR v. West, 11 Vet. App. 393, 399 (1998). The Manual also notes that since personal assault, to include sexual assault, can be an extremely personal and sensitive issue, many incidents of personal assault are not officially reported, making it difficult to obtain direct evidence, and requiring that the alternative evidence be sought. Id. Under § 3.304(f)(3), if a PTSD claim is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases, and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(3) (2012). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background The Veteran contends that he has PTSD due to an in-service personal assault. Specifically, at his May 2011 hearing before the undersigned, the Veteran testified at length that he was the victim of personal assaults in service. The Veteran described being attacked by a gang of African American service members while sleeping and while in the shower. He described how this caused him to get out of service early and how it has affected his life since service. He described sabotaging his service career after the events, receiving Article 15's and eventually being put out of service early as consequences of the assaults. He testified that he believed that his current mental health problems are due to these incidents. The Veteran's service treatment records are negative for treatments or complaints related to a psychiatric disability. They are also negative for complaints or reports of incidents where the Veteran was attacked by fellow servicemembers. The Veteran's personnel records contain incidents of insubordination. For example, on May 5, 1985, the Veteran failed to obey a lawful order to go clean his day room. The personnel records contain numerous Article 15's which were issued for insubordination. Namely, on June 3, 1985, June 15, 1985; and June 25, 1985, he failed to go to his appointed place of duty at the time prescribed. As a result, the Veteran was released from active duty in July 1985 for transfer to the Individual Ready Reserve due to him being "immature and unable to adjust to military life", to not responding to counseling and or disciplinary measures and that his poor conduct and general attitude was unacceptable as reflected by his repeated offenses of missing formation, disobeying orders and failure to repair. The Veteran underwent a consultative examination at the Arrowhead Psychological Clinic in April 1999. The private psychologist noted that it was rather difficult to get a good history from the Veteran. He did report that he had experienced several traumatic deaths of those who were close to him. He did not report other specific problems. There was no Axis I diagnosis. The Axis II diagnosis was personality disorder NOS. A November 2009 VA mental health treatment report indicated that the Veteran reported nightmares related to an incident where fellow soldiers attempted to sexually assault him. He reported that he fought them off. He also reported physical fights with other soldiers while in the military. The Axis I diagnosis was chronic PTSD and bipolar disorder NOS. A December 2009 VA treatment report noted the Veteran was admitted to the PTSD residential program at the facility. The Veteran reported that he was angry because he joined the military to become a military policeman (MP) but once he was in the service he was told that he was too short. He then became a small motor mechanic. He stated that he was given an early training discharge because of being overweight. However, he believed the real reason was because he got into so many fights and would not take orders from superiors. He very much resented this and other perceived mistreatments he experienced in the service and still ruminated upon them daily. He felt that his life was ruined because he could not finish the service. He relayed another military experience where he was hit in the mouth by another soldier and fought back. He reported that he was singled out and reprimanded for this incident. He then reported that on one occasion, he was surrounded by African American soldiers while he was sleeping. When they woke him up, one of the soldiers had exposed his penis to the Veteran and placed it on his pillow. The Veteran stated that he "freaked out" and fought back. After a brief fight the other soldiers left. He stated that it might have been a joke but he did not find it funny. He detailed other incidents where he was ridiculed in the shower for the size of his penis. He then avoided showering when anyone else was around. The other soldiers thought he was not showering and gave him a "blanket party" which resulted in further humiliation. On after further prompting, the Veteran described witnessing the death of a soldier by another soldier in basic training. The physician noted that the Veteran was very animated and vocal when describing these instances. The physician considered the Veteran's primary diagnosis to be a longstanding adjustment disorder to his experiences in the military with an accompanying Axis 2 personality disorder. The physician noted that in November 2009, the Veteran described the incident in which he was targeted by other men in the military who were attempting to have sexual interactions with him as the traumatic event. However, on the current assessment, he did not describe this incident as his traumatic or distressing military experience not did he describe it as life threatening. A January 2010 VA mental health interdisciplinary plan of care note reported that the primary concern regarding the Veteran was PTSD. At a January 2010 VA psychotherapy session, the Veteran reported that his primary "trauma" was being discharged from the military "just like that". However, the Veteran's prior assessments outline a history of negative behavior and disciplinary actions leading up to his discharge. He also described a single episode of being sexually harassed in the military. The diagnosis was anxiety disorder NOS A January 2010 psychology note reported that the Veteran's responses on the PTSD checklist were of uncertain validity due to his rating multiple trauma experiences. In a March 2010 VA treatment note, the Veteran reported that one day while in the service, he woke up and 3 men were molesting him. He indicated that one of the men had his penis in his face. The diagnosis was PTSD and bipolar disorder. In a March 2010 stressor statement which accompanied the Veteran's substantive appeal, the Veteran contended that his sexual assault at the hands of a few soldiers resulted in his early release from service due to poor performance and conduct. The Veteran claimed that in February 1985, while in Basic Training at Fort McClellan in Alabama, he was awoken by 3 African American men in the middle of the night. One of the men placed his penis on the Veteran's pillow while the others started pulling on his bed and telling him that they were "gonna get him". The Veteran also claimed that in June 1985 while stationed in Fort Belvoir, Virginia, he was in a shower when an African American soldier started ridiculing him about the size of his penis. The soldier also began to "rub up on" the Veteran. After this incident, the Veteran claims that he took showers at night. The Veteran underwent a VA examination in October 2010. The Veteran reported that after receiving an Article 15 in the service for not buffing the floor when he was instructed to buff the floor, the Veteran decided he would do what he could do to get kicked out of the military. Shortly after, he refused to show up for formation and also threw the contents of his locker in a manner that would fail inspection. Testing results demonstrated that the Veteran overendorsed items of the MMPI-2. The examiner noted that on the Clinician Administered PTSD Scale, the Veteran failed to meet the criteria for PTSD as there was difficulty accurately assessing the Veteran's PTSD symptomatology in part because of his pattern of overendorsement of symptoms. The one event that he described that appeared to meet the pattern of Criterion A involved an attempted sexual assault. He described an incident where 3 or 4 African American soldiers approached him at night showing him their genitals and telling him that they were going to sexually assault him. He fought back physically and was able to repel them to the point where they fled. The examiner noted that the Veteran had many instances of physical assaults and fights throughout his life. Therefore, it was difficult to separate the effects of a single event that occurred in the military as compared to multiple physical altercations that he endured. He met Criterion B for PTSD as he thought about his attempted sexual assault in the military nearly every day. He did not meet Criterion C for PTSD as he did not have persistent avoidance of stimuli and numbing of general responsiveness. The examiner concluded that test results and interview data indicated that the Veteran failed to meet criteria for PTSD. He had symptoms of the disorder but they failed to meet the full diagnostic criteria. It was unclear whether these symptoms stem directly from the attempted sexual assault or a lifetime of physical altercations and it was impossible to determine without resorting to mere speculation that the attempted assault has resulted in his current impairment. Instead, what is described as a persistent history of antisocial behavior which appeared to stem back to at least the Veteran's high school years. Additionally, he has been dependent on on several illicit substances. The Axis I diagnosis was anxiety disorder, cocaine dependence, cannabis dependence and alcohol disorder. The Axis II diagnosis was antisocial personality disorder. In a February 2011 Memorandum, the Joint Services Records Research Center (JSRRC) Coordinator at the St. Paul RO determined that the information required to cooborate the stressful events described by the Veteran were insufficient to send to JSSRC. The Memorandum noted that the Veteran stated that he witnessed the death of a soldier by another soldier. Discharge documents contained no combat awards or decorations and the service treatment records contained no treatment for anxiety or depression during service. A review of the personnel records also contained no information pertaining to a claimed stressor and research found no record of the alleged incidents. Per the October 2011 Board remand instructions, the Veteran underwent a VA examination in December 2011. The examiner determined that the Veteran did not have a diagnosis of PTSD that conformed to DSM-IV criteria based on the evaluation. His symptoms did not meet the diagnostic criteria for PTSD under DSM-IV criteria. He did have another Axis I diagnosis of an anxiety disorder NOS, nicotine dependence, alcohol dependence in sustained partial remission and a history of cocaine and cannabis dependence. An Axis II diagnosis of personality disorder NOS was provided. The Veteran had more than one mental disorder diagnosed and it was not possible to differentiate what symptoms were attributable to each diagnosis. The examiner did determine that while the symptoms overlapped, his personality disorder was primary. The examiner indicated that the attempted sexual advances during the military service aggravated the Veteran's personality disorder symptoms by increasing the Veteran's difficulties feeling generally safe in the world and by specifically worsening his distrust of others. The examiner noted the Veteran's reported stressors which were detailed in a March 2010 stressor statement which accompanied the Veteran's substantive appeal. Notably, the Veteran claimed that he was assaulted by 3 African American while he was sleeping with one of the men exposing himself while the others issued threats of a sexual nature. The examiner remarked that while the Veteran claimed that this incident occurred in February 1985 while he was stationed at Fort McClellan, at his May 2011 hearing he testified that the incident took place while he was stationed in Fort Belvoir. The Veteran also claimed that an incident occurred when he was showering and another soldier ridiculed him and then tried to "hug up on" the Veteran. The examiner also noted that in an April 1999 consultative psychiatric evaluation, the Veteran reported that he experienced several traumatic deaths of people that were close to him. He did not report other specific problems related to emotional issues. The examiner reported that the Veteran's post-military treatment began in 1998 but that this treatment was for back pain, right hand pain and numerous physical issues. A progress note in 1997 indicated that the Veteran was taking Prozac as he had depression and personality issues. However, the depression was related to pain issues. The examiner reported that the Veteran had been assigned diagnoses of PTSD, anxiety disorder NOS, bipolar disorder, depression and substance abuse disorders. It appeared however, that there was not a structured, in depth interview regarding his PTSD symptomatology. Some notes indicated trauma related to childhood and furthermore, the diagnoses were sometimes qualified by the words "by history". The Veteran met criterion A, criterion B, criterion C and criterion D. However, the Veteran did not meet the full criteria for PTSD as he did not meet criteria E or F. The examiner indicated that on psychological testing, the validity scale scored indicated that the Veteran's response style was overly inclusive leading to a significant endorsement of items consistent with emotional distress and life dissatisfaction. As such, the resulting profile was marginally valid and should be interpreted with caution as it may over pathologize the Veteran's symptoms. The Veteran's endorsements were likely exaggerated which indicated some distortion in thoughts, mistrust, paranoia and social isolation. The examiner also noted that the Veteran reported that he began to feel depressed after his discharge from the military. Although he likely had depressed mood and other symptoms of depression, it does not appear that these episodes met the criteria for a major depressive episode. Regarding the reported traumas, the examiner noted that although the alleged assault that reportedly occurred when the Veteran was sleeping in the barracks likely met criterion A for PTSD, the Veteran reported numerous instances of suspiciousness of other's motives, physical fights and inaccurate perceptions of/overreactions to others' behaviors prior to this incident. It was also difficult to assess the Veteran's symptoms for one specific traumatic event due to the Veteran's circumstantial style of communication as well as his tendency to discuss symptoms of multiple experiences at once. The difficulty in accurately assessing his PTSD symptomatology was also in part due to his tendency to overendorse symptoms but vaguely describe them. It was also difficult to separate the effects of a single event that occurred in the military as compared to the multiple physical altercations that he endured. Thus, the diagnosis of PTSD could not be provided based on the report for one specific trauma. The diagnosis of anxiety disorder NOS was assigned for the reported re-experiencing, avoidance and arousal symptoms that the Veteran endorsed which were related to the attempted sexual assaults that occurred in the shower and the barracks. The examiner also noted that the Veteran's motivation for joining the military provided insight to his character as he wanted to join the military to "get back at anyone who stuck up for those who killed our soldiers in Beirut". Once in the military, he experienced many disappointments and also noted at one point feeling recycled and ridiculed for not keeping up with training. Other perceived mistreatments included feeling singled out and reprimanded. He also noted that he had felt his purpose in life was "to be a solider" and to be "a killing machine". The progress notes indicated that the Veteran continued to ruminate upon the perceived mistreatment he received in the service. His reports of the most significant/traumatic events had been variable and generally absent until approximately 2008. The examiner noted that even after the Veteran began sharing details about his experiences in the military, it was still unclear when and where the attempted sexual assaults occurred; whether there were 3 or more separate incidents or whether some of the separate scenarios, as he reported today, occurred together as noted in the March 2010 stressor statement; and which events the Veteran reported as the most significant. The examiner indicated that at the examination today, the Veteran did not report his primary stressor of being assaulted by 3 African American soldiers as he slept. He also did not note this stressor upon his admission to the PTSD residential program in December 2009. It was also noted at the evaluation that when asked what his most distressing moment in the service was, the Veteran indicated that it was when he was on the plane home after his discharge and he realized that he had erred and that "it was over" and he could not fix it. The examiner opined that it was less likely than not that the Veteran's service treatment records support that he was a victim of personal assault. The opinion was based on the numerous disciplinary actions in the military beginning in May 1985, the absence of behavior problems for 3 months after the alleged assault in February 1985, and the Veteran's behaviors related to fighting, authority and anger which were noted prior to the military (with a teacher) as well as in December 1984 when he went home from leave and was either attacked or called a derogatory name which resulted in him engaging in a fight that caused long-standing hand problems. Additionally, there was questionable credibility based on inconsistent reports in documents of alcohol use before and during the military, a tendency to exaggerate current symptoms, the examiner's perception that the Veteran minimized childhood difficulties/adjustment, the report of his most significant traumas, minimizing and blaming behaviors, various emotional reactions to various emotional traumas and unclear (and apparently inconsistent) report/documentation of where and when the specific attempted assaults occurred (and if some occurred together as noted in the stressor statement). The examiner opined that in the absence of a report/documentation of these attempted sexual assaults while in the military and conflicting evidence and questionable credibility as well as personality issues related to blame, anger, fighting and authority problems that likely predated his military service; the Veteran's documented disciplinary actions in the service treatment records less likely than not provide sufficient evidence to indicate a behavior change in the military. Thus, there did not appear to be other forms of evidence to indicate that the Veteran was a victim of personal assault(s) and it was less likely than not that the Veteran's service treatment records support that he was a victim of personal assault(s). The examiner clarified that this was not to say that the assaults did not occur, but rather that there was minimal documentation in the Veteran's claims file to provide objective evidence of the event(s). The Axis I diagnosis was anxiety disorder NOS. This condition was provided for the reported mild depressive symptoms, rumination of perceived mistreatments he experienced in the service as well as the re-experiencing, avoidance and arousal symptoms that the Veteran endorsed that were related to the sexual assaults that occurred in the shower and the barracks. However, the examiner noted that the etiology of this condition was "probably two-fold" as it was a result of his personality disorder which predisposed him to feel distrusting, suspicious and easily victimized; and the experience of the alleged events that occurred during the service. The examiner noted that given that there was an attempted assault, it was as likely as not that the condition was at least partially related to his military alleged assaults and military service. The Veteran also had an Axis I diagnosis of substance abuse disorders which were reported to be forms of self-medication. It was at least as likely as not that the Veteran's difficulties with substance dependence and abuse were secondary to the distress associated with the sequela of personality pathology and subsequently to symptoms of anxiety disorder NOS. The Axis II diagnosis was personality disorder with antisocial and paranoid features. According to the examiner, this condition more likely than not existed prior to the Veteran's military service. However, it was also more likely than not that the events and perceived stressors that occurred during the Veteran's military service aggravated his personality disorder symptoms by increasing his difficulties with feeling generally safe in the world and by specifically worsening his distrust of others. The December 2011 VA examiner opined that the diagnosis of anxiety disorder NOS was provided for the reported mild depressive symptoms, rumination of perceived mistreatments he experienced in the service and the re-experiencing, avoidance, and arousal symptoms he endorsed that were related to the attempted sexual assaults that occurred in the shower and the barracks. Due to his personality characteristic, the Veteran was more susceptible to experiencing additional psychiatric problems and difficulties in his life. Thus, the examiner concluded, his personality disorder was more likely than not aggravated by his military service. Additionally, the mental health issues that reported began in the military (diagnosed here as anxiety disorder NOS, which includes PTSD-like symptoms, ruminative symptoms and mild depression) are as likely as not related to stressors that may have occurred during his service. Regarding service connection for PTSD, as noted, service connection for PTSD requires a medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) (i.e., Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). 38 C.F.R. § 3.304(f). In this case, the weight of the persuasive medical evidence demonstrates that the Veteran does not currently have a diagnosis of PTSD, nor that he had such disability during the course of the appeal. The Board notes that a November 2009 VA mental health treatment report, a January 2010 VA mental health interdisciplinary plan of care note and a March 2010 VA treatment note provided a diagnosis of PTSD. In contrast, a January 2010 psychology note reported that the Veteran's responses on the PTSD checklist were of uncertain validity due to his rating multiple trauma experiences. Additionally, both the October 2010 and December 2011 VA examinations determined that the Veteran did not meet the full criteria for a diagnosis of PTSD. The credibility and weight to be attached to medical opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such clinical data or other rationale employed by the physician and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Sklar v. Brown, 5 Vet. App. 140 (1993). In this case, the Board has afforded more weight to the October 2010 and December 2011 VA examiners' opinions, than to the opinions found in the November 2009, January 20101 and March 2010 VA treatment notes. The VA examiners had the opportunity to review the claims file and to conduct a personal examination of the Veteran. In addition, the examiners provided an in-depth analysis of the Veteran's mental status; specifically cited DSM-IV criteria; and explained in detail why the criteria for a diagnosis of PTSD were not met. Additionally, the December 2011 VA examiner specifically noted that while the Veteran had been previously assigned a diagnosis of PTSD, it appeared that there was not a structured, in depth interview regarding his PTSD symptomatology and some notes indicated trauma related to childhood and furthermore, the diagnoses were sometimes qualified by the words "by history". In light of the thoroughness of the October 2010 and December 2011 VA examination reports, the conclusiveness of the findings contained therein, and the fact that these examiners had access to the Veteran's entire claims folder, the Board placers greater probative values on the findings rendered by these examiners. Regarding an acquired psychiatric disorder other than PTSD, the Board notes that if psychosis becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of psychosis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. After having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against a finding that an acquired psychiatric disorder, such as anxiety disorder NOS, had its onset in service. As noted above, the Veteran's service treatment records are negative for treatment or complaints related to an acquired psychiatric disability and there are no clinical findings or diagnoses of an anxiety disorder or any psychiatric disability during service or for several years thereafter. The first documented medical evidence of a psychiatric disorder is the progress note in 1997 indicated that the Veteran was taking Prozac as he had depression and personality issues. This note is over 12 years after the Veteran's discharge from service. Thus, there is no evidence that psychosis was manifested in the first post service year (so as to trigger application of presumptive provisions in 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309 for such chronic disease). The Board also points out that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). The Board notes that in the December 2009 VA treatment note, a physician opined that the Veteran had a longstanding adjustment disorder to his experiences in the military. Additionally, the December 2011 VA examiner concluded that the Veteran's Axis I diagnosis of anxiety disorder NOS was "at least partially related to his military alleged assaults and military service." However, the October 2011 Board remanded also specifically instructed the examiner to opine as to whether it is at least as likely as not that the Veteran is the victim of personal assault as alleged Board. Accordingly, the examiner determined that that it was less likely than not that the Veteran's service treatment records support that he was a victim of personal assault. This opinion by the VA examiner finding it less likely than not that a personal assault was supported by the service treatment records was based on the numerous disciplinary actions in the military beginning in May 1985, the absence of behavior problems for 3 months after the alleged assault in February 1985, and the Veteran's behaviors related to fighting, authority and anger which were noted prior to the military. The examiner opined that in the absence of a report/documentation of these attempted sexual assaults while in the military and conflicting evidence and questionable credibility as well as personality issues related to blame, anger, fighting and authority problems that likely predated his military service; there did not appear to be other forms of evidence to indicate that the Veteran was a victim of personal assault(s) and it was less likely than not that the Veteran's service treatment records support that he was a victim of personal assault(s). As also noted by the December 2011 VA examiner, VA treatment records prior to 2008 are entirely negative for complaints or diagnoses related to military sexual trauma as the Veteran first began reporting his claimed trauma(s) first in 2008. Significantly, multiple treatment notes have also indicated that the Veteran's credibility regarding his claimed stressors was not reliable. Notably, in the August 2009 VA treatment note, the Veteran described witnessing the death of a soldier by another soldier in basic training. However, the Veteran made no mention of this stressor in subsequent stressor statements or during his later treatment. Moreover, the January 2010 psychology note reported that the Veteran's responses on the PTSD checklist were of uncertain validity due to his rating multiple trauma experiences. Finally, as noted above, the December 2011 VA examiner opined that the Veteran had questionable credibility as he did not report his primary stressor of being assaulted by 3 African American soldiers as he slept during the examination, he did not note this stressor upon his admission to the PTSD residential program in December 2009, and when asked what his most distressing moment in the service was, the Veteran indicated that it was when he was on the plane home after his discharge. While the December 2011 VA examiner attributed the Veteran's anxiety disorder NOS to his claimed military stressors to include attempted sexual assault, the examiner also determined that it was less likely as not that the Veteran was a victim of a personal assault in-service based upon his service treatment records. Similarly, as the finder of fact, the Board concludes that he Veteran's reports of in-service personal assault are not credible. As noted, he has provided conflicting stories regarding the timing and location of the assault and has failed to supply any collaborating evidence such as lay statements from others, police reports, or contemporaneous treatment records. To the extent that the Veteran claims that his behavior problems resulted from the alleged assaults, the Board observes that VA examiners have consistently opined that he has a personality disorder. As there is no support in other forms of evidence to indicate that the Veteran was a victim of personal assaults and it was less likely than not that the Veteran's service treatment records support that he was a victim of personal assault, the Board finds that the opinions finding a relationship between the Veteran's current psychiatric disorders and claimed in-service personal assaults that "may have" occurred not probative on the issue of whether the Veteran currently experiences a current psychiatric disability which may be attributed to active service. The Board also notes that the Veteran has a primary diagnosis of a personality disorder. There is also some question as to whether the Veteran's personality disorder preexisted service and was aggravated by service. However, congenital or developmental defects (including personality disorders) are not diseases or injuries within the meaning of the applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9 (2012); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996) (a personality disorder is not the type of disease-or-injury related defect to which the presumption of soundness can apply). While service connection for personality disorder is barred by regulation, where a personality disorder is aggravated by active military service, compensation remains available. See VAOPGCPREC 82-90 (a disease which is considered by medical authorities to be of familial (or hereditary) origin must, by its very nature, be found to have pre-existed a claimant's military service, but service connection could be granted if there is superimposed injury or disease in service and the preexisting disorder is aggravated (permanently increased in severity) during service). As noted above, the December 2011 VA examiner determined that the Veteran's personality disorder preexisted his service and that it was also more likely than not that the events and perceived stressors that occurred during the Veteran's military service aggravated his personality disorder symptoms by increasing his difficulties with feeling generally safe in the world and by specifically worsening his distrust of others. However, this opinion is based on the assumption that his in-service assaults occurred. As noted above, there is no support in the Veteran's service treatment records for his assertion of an in-service stressor of personal assaults. Accordingly, because it was less likely than not that the Veteran's service treatment records support that he was a victim of personal assault, a preexisting personality disorder aggravated by these stressors is not supported by a factual predicate in the record or any clinical data or other rationale. In reaching the foregoing conclusions, the Board has considered the lay evidence offered by the Veteran to VA. This includes his statements and the statements of his representative in which they asserted their belief that the Veteran's claimed psychiatric disability, to include PTSD, is related to his in-service assaults. As noted above, multiple treatment providers noted that the validity of the Veteran's presentation was questionable. Specifically, in finding that it was less likely than not that the Veteran was the victim of personal assault as alleged, the December 2011 VA examiner noted that there was questionable credibility of the Veteran based on inconsistent reports in documents. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, lay persons are not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999); see also Espiritu v. Derwinski, supra. To the extent that the Veteran and his representative's assertions are offered to establish a relationship between the current claimed disabilities and a service-connected disability, such evidence must fail. The matter of medical etiology, or relationship-the matter on which these claims turn-is within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran and his representative are not shown to be other than laypersons without the appropriate medical training and expertise, they are not competent to render a probative (i.e., persuasive) opinion on a medical matter. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, supra. See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Moreover, to the extent that the holding in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) can be interpreted to enable a lay person to speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg, the question of causation here involves a more complex relationship that the Veteran and his representative are not competent to address. Hence, the lay assertions in this regard have no probative value. The Board finds that the competent evidence of record, while showing currently diagnosed acquired psychiatric disabilities, does not demonstrate psychosis manifested to a compensable degree within one year of separation or related to an in-service injury sustained by the Veteran. In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for an acquired psychiatric disorder. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for psychiatric disability to include PTSD is denied. REMAND As noted above, the Board remanded these matters in October 2011 for further development. Specifically, the Board instructed the RO to provide medical opinions for the claims for service connection for a right wrist disability and a right upper arm disability, both including as secondary to service-connected residuals of fracture of the second right metacarpal. The remand instructions included providing an etiological opinion, to include whether any current right wrist disability or right upper arm disability was related to service. The instructions also specifically stated that: The examiner should provide an opinion with respect to each currently present right wrist and arm disorder as to whether there is a 50 percent or better probability that the disorder was present in service or is otherwise etiologically related to service or service-connected disability. The Board noted that the Veteran alleges that his service-connected residuals of fracture of the second right metacarpal have caused right wrist and arm disabilities. Pursuant to the Board's remand, the Veteran was afforded an examination in December 2011. While the examiner addressed whether the Veteran's right wrist and right arm disabilities were related to service, she did not address the Veteran's right wrist or right arm disability on a secondary basis as instructed by the Board. The examination report does not comply with the Board's October 2011 instructions. The United States Court of Appeals for Veterans Claims has held that a remand confers on the veteran, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). On remand, the December 2011 VA examiner should amend her examination report in accordance with the Board's October 2011 directives cited herein. Accordingly, the case is REMANDED for the following action: 1. The RO should arrange for the same examiner who conducted the December 2011 examination, if possible, to review the claims folder and determine whether the Veteran's right arm and right wrist disabilities are etiologically related to, or aggravated by, his service-connected residuals of fracture of the second right metacarpal disability. If the December 2011 examiner is unavailable, the file should be referred to another similarly qualified medical professional. The examiner should furnish an opinion as to whether it is at least as likely as not that the Veteran's right arm or right wrist disabilities are (1) proximately caused by or (2) aggravated by his service-connected residuals of fracture of the second right metacarpal disability. If the examiner finds that the Veteran's right arm or right wrist disabilities have been made worse by his residuals of fracture of the second right metacarpal disability, to the extent feasible, the degree of worsening should be identified. The examiner should fully describe the objective findings that support his or her conclusions. If the reviewer finds that diagnostic testing of the Veteran is necessary, such should be accomplished. All necessary tests should be performed. The claims folder should be made available to the examiner in conjunction with the examination, and the examiner must indicate on the examination report that such a review was undertaken. The rationale for all opinions expressed should be set forth. If an opinion cannot be formed without resorting to mere speculation, the examiner should so state and provide a reason for such conclusion. 2. Ensure that the examination report complies with this remand and answers the questions presented herein. If any report is insufficient, it should be returned to the examiner for necessary corrective action, as appropriate. 3. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claims. If any benefit sought remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs