Citation Nr: 1304829 Decision Date: 02/11/13 Archive Date: 02/21/13 DOCKET NO. 10-09 666 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL Appellant and wife ATTORNEY FOR THE BOARD M. C. Graham, Counsel INTRODUCTION The Veteran had active service from June 1962 to March 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran testified before the undersigned Veterans Law Judge in September 2012. A copy of the transcript of this hearing has been associated with the claims files. The record demonstrates that the Veteran has multiple psychiatric diagnoses including major depressive disorder, schizoaffective disorder, adjustment disorder, a cognitive disorder, dementia, and PTSD. In the July 2012 supplemental statement of the case, the RO readjudicated the claim to include any acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this regard, the Board notes that the Veteran was denied service connection for depression in a February 2009 rating decision and was denied claims to reopen claims for service connection for brain damage, also claimed as traumatic brain injury and brain disease with cognitive issues including memory loss, and depression as secondary to brain damage in an August 2010 rating decision. As he did not initiate appeals with respect to the February 2009 and August 2010 denials, the Board finds no basis for additional development and adjudication of those claims pursuant to Clemons. To the extent that the Veteran seeks to reopen a claim for traumatic brain injury (TBI) (see September 2012 hearing transcript at 6), that issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran's claimed in-service personal assault stressor has not been corroborated. 2. The Veteran did not engage in combat while in service. 3. There is no competent and credible evidence that any acquired psychiatric disorder had its onset in service, that a psychosis manifested within one year of service discharge, or that any current acquired psychiatric disorder is related to his active military service. CONCLUSION OF LAW A chronic acquired psychiatric disorder, including PTSD, was not incurred in or aggravated by service; and psychosis may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304(f), 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Duties to Notify and Assist VA has duties to notify and assist the Veteran in substantiating these claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record: (1) that is necessary to substantiate this claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a SOC or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, a May 2008 letter was sent prior to initially adjudicating the claim for service connection for PTSD in the July 2008 rating decision at issue in this appeal. In November 2010, the Veteran for the first time claimed that he had PTSD as a result of personal assault in service (previously he had contended that he had PTSD prior to service that was aggravated by an in-service head injury), so in February 2011 he was provided with a VCAA letter that specifically dealt with PTSD based on personal assault. The claim was thereafter readjudicated in a July 2012 supplemental statement of the case, curing any timing defects. These letters informed the Veteran of the type of information and evidence required to substantiate claims for service connection, including the specific requirements of claims for PTSD (including based on personal assault in the case of the February 2011 letter), and apprised him of his and VA's respective responsibilities in obtaining this supporting evidence. He also was advised of the downstream disability rating and effective date elements of these claims in the both letters. See Dingess/Hartman, supra. Thus, the Board finds that he has received all required VCAA notice concerning this claim. Moreover, he has not alleged any prejudicial error in the content or timing of the VCAA notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), he, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content and, moreover, that it is unduly prejudicial - meaning outcome determinative of his claim. Thus, absent this pleading or showing, the duty to notify has been satisfied. And as for the duty to assist, the RO obtained the Veteran's available service treatment records (STRs), service personnel records, private medical records, worker's compensation records, Social Security Administration (SSA) records, and VA treatment records. The RO also contacted Air Force Office of Special Investigations to try and corroborate the Veteran's assertions of personal assault in service, but no records were found indicating he had ever been involved in a criminal investigation. The Veteran also underwent VA compensation examinations in June 2008 and June 2010 which included medical opinions concerning the determinative issue of whether any current mental disorder or PTSD is related to his military service, including on an aggravation basis following an incident when he hit his head on the bottom of a pool. The reports of these examinations address the Veteran's contentions and contain the findings needed to make this critical determination of causation and properly adjudicate this claim. Another examination or additional medical comment is not needed. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection 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); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). Although a VA examination was not scheduled to obtain a medical opinion as to whether the Veteran has PTSD due to personal assault in service, the Board finds that such an examination is not necessary. As discussed in further detail below, the record currently on appeal contains no evidence corroborating the Veteran's claim that he was assaulted during service. Consideration has been given to 38 C.F.R. § 3.304(f)(5), which provides that VA may submit any evidence it has to a VA mental health professional to obtain an opinion as to whether a personal assault occurred. However, the Veteran has yet to submit any credible supporting evidence. There is simply no evidence to provide to an examiner other than the Veteran's personal statements, which are not deemed credible. Thus, an examination is not required here, even under the low threshold of McLendon v. Nicholson, 20 Vet. App. 79 (2006). 38 U.S.C.A. § 5103A(d)(2); and 38 C.F.R. § 3.159(c)(4). The Veteran and his wife provided additional evidence in the form of testimony during the September 2012 hearing before the undersigned. The issue on appeal was identified. The Veteran was also asked to provide evidence pertaining to his in-service stressor as well as any other evidence that would relate his psychiatric disorder to his active service. There was no other indication or allegation that relevant evidence remains outstanding. The Board concludes that all the available records and medical evidence have been obtained in order to make a determination as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist. Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Law and Regulations The Veteran has made various assertions regarding the origin of his current psychiatric condition during the course of this appeal. Most recently, during his September 2012 hearing, he indicated that he believes "the root" of his current psychiatric problems is a scalp laceration ("head injury") he sustained in service. When he initiated this claim in September 2006, he asserted that he was diagnosed with PTSD in service and his PTSD was aggravated when he sustained a scalp laceration in service. In November 2010 he asserted for the first time that he was sexually assaulted in boot camp/basic training which led to his current psychiatric condition. Generally, service connection may be established for 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 be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran is presumed to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrated that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). If the disorder was not noted upon entry, the presumption of soundness may be rebutted by a showing, by clear and unmistakable evidence, both that a disease or injury existed prior to service and that the disease or injury was not aggravated by service. 38 U.S.C.A. § 1111; VAOPGCPREC 3-2003 (July 16, 2003). Clear and unmistakable evidence means that the evidence cannot be misinterpreted and misunderstood, i.e., it is undebatable. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Service connection for certain "chronic" diseases, such as psychoses, may also be established based on a legal presumption by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection specifically for PTSD requires: (1) medical evidence establishing a diagnosis of the disorder; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) a link established by medical evidence, between current symptoms and an in-service stressor. 38 C.F.R. § 3.304(f). The PTSD diagnosis must be made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 38 C.F.R. § 4.125(a). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether a veteran engaged in "combat with the enemy." See Gaines v. West, 11 Vet. App. 353, 359 (1998). If VA determines that a veteran engaged in combat with the enemy and his alleged stressor is combat-related, then his lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required- provided that such testimony is found to be "satisfactory," i.e., credible and "consistent with circumstances, conditions or hardships of service." See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f)(1); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). If, however, the alleged stressor is not combat-related, then the veteran's lay testimony, in and of itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates his testimony or statements. See Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996). Recent regulatory amendments changed the evidentiary standards regarding stressors based on a veteran's fear of hostile military or terrorist activity. 38 C.F.R. § 3.304(f)(3)(2012). The Veteran's service personnel records reflect that his military occupational specialties were as a construction helper, a structural and pavement helper, and an aircraft maintenance specialist. The service records do not show foreign service or indicate that he was in receipt of awards or decorations indicating combat service. He does not argue the contrary. Hence, the alleged PTSD stressor is not alleged to be the result of combat or fear of hostile military or terrorist activity. Thus, in order to prevail on his claim, the evidence must reveal a diagnosis of PTSD based on the alleged stressor and credible supporting evidence that the claimed in-service stressor occurred. In the alternative, there must be evidence of an acquired psychiatric disorder that is etiologically related to or aggravated by his active military service. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 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, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 3.102. III. Factual Background The STRs do not reveal complaints, treatment, or diagnosis of any psychiatric disorders. The Veteran's discharge examination indicated a normal psychiatric evaluation. There is also no evidence of a diagnosis of a psychosis within one year of service discharge. Indeed, it is not until several years after service that a psychiatric problem is identified. The STRs do show that in May 1963 the Veteran cut his head after diving into a pool. The laceration was treated with stitches, a skull (X-ray) series was negative, and the discharged examination noted "NC or S", or no complaints or subjective findings. Post-service records also show that the Veteran reported additional head injuries. See, for example, February 2001 written report of Dr. Bartol wherein the Veteran reports multiple head injuries "including his brother putting an 8-inch nail in his head." Post-service treatment records include a July 1987 record which noted that the Veteran sustained an on the job injury in January 1986 that resulted in a loss of consciousness for 10 minutes after he was struck by a bulk head on a crane and thrown 10 to 12 feet into the side of a box car. A September 1987 psychiatric evaluation by Dr. R. Smith found no Axis I diagnosis and concluded that there was no relationship between the Veteran's January 1986 injury and his present mental condition. The examiner noted that the Veteran had Axis II diagnoses of mixed personality disorder with dependent, asocial, borderline, and paranoid features. A January 1988 record from Crook County Mental Health opined that the Veteran's "level of functioning is further evidence of his brain injury related to a past history of substance use." An April 1999 VA mental health record diagnosed the Veteran with PTSD "related to childhood physical and sexual abuse;" alcohol dependence, reportedly in remission; and rule out schizoaffective disorder. The assessment was that his "polysubstance abuse . . . and chronic mood difficulties [were] related to a history of severe childhood sexual and physical abuse." A July 1999 written statement from a VA nurse practitioner, K. Inaba, noted that the Veteran believed his depression was due to an incident in service (noted in the STRs) when he had paint remover spilled on his body. However, K. Inaba concluded that the "veteran suffers from chronic post-traumatic stress disorder related to childhood physical and sexual abuse and is recovering from alcohol dependence." She made no finding regarding the Veteran's service other than noting his reported history. LeShore v. Brown, 8 Vet. App. 406 (1995) (the mere transcription of medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional.) In October 2000, the Veteran was hospitalized with a diagnosis of adjustment disorder attributed to "the likelihood of losing his house to his girlfriend." He was also diagnosed with PTSD, a cognitive disorder, and polysubstance abuse in sustained remission. After reviewing the Veteran's chart extensively, Dr. W. Hoffman, a VA staff psychiatrist concluded that he "[a]gree[d] with assessment that his 'hallucinations' are dramatic descriptions of internal dialogue and not true hallucinations." The Veteran underwent a series of psychological testing that led to a diagnosis of adjustment disorder with anxiety and depressed mood by the psychologists. They noted that his personality tests (MMPI-2 and PAI) were invalid due to inconsistent responding and both over and under reporting which "suggests caution in drawing conclusions from [the Veteran's] self-report statements." It was noted that the etiology of his impairments were difficult to ascertain due to the fact that he was a questionable historian, in addition to his anxiety. A June 2006 record noted that the Veteran had PTSD concerns and may have "possible problems related to PTSA . . . ." A June 2008 VA scars examiner, Dr. A. Doyle, concluded that, since the Veteran denied having any problems with dizziness, fainting spells, and loss of memory or amnesia in a March 1964 service record, a year after the 1963 head laceration, "[t]his makes it highly unlikely that these symptoms, appearing late in life after a long tobacco and alcohol use history and with extensive small vessel disease present, are attributable to that trauma . . . ." A June 2008 PTSD examiner, Dr. Dillon, diagnosed schizoaffective disorder; cognitive disorder, NOS; PTSD "related to childhood trauma"; and alcohol dependence. The examiner stated that it was "possible" that the cognitive disorder is related to the pool incident, but "[w]ithout resorting to mere speculation, none of the above diagnoses appear related to his military service." Specifically with respect to PTSD, the examiner stated: The veteran also appears to describe symptoms of post traumatic stress disorder. These symptoms include intrusive thoughts and memories of sexual assaults when he was a young child. He also describes symptoms of arousal, numbing and avoidance related to these childhood events. The veteran does not describe symptoms of post traumatic stress disorder related to his head injury. It is likely that his diving into the pool does not meet diagnostic criteria for a Criterion A stressor. Even so, the veteran does not describe intrusive thoughts and memories from this event to include the necessary distress directly related to the pool incident. The examiner noted that the Veteran had been diagnosed with schizoaffective disorder for "years" due to reported auditory and visual hallucinations. The Board notes that the Veteran described in his October 2000 hospital record that "the voices were 'friends' he created soon after his sexual abuse as a child, as a way of coping." A September 2008 treatment note prepared by Dr. B. Vignola noted that the Veteran was seeking service connection and stated "[i]t is certainly my opinion that the head injuries could cause brain injury as well as contribute to a diagnosis of PTSD, chronic, related to his time in the service." She added, "[t]here is no doubt that he meets the diagnosis of PTSD from childhood, and that would predispose him to PTSD in adulthood in certain circumstances." In June 2010 the Veteran underwent a VA PTSD examination. The examiner, Dr. D. Scharf, specifically noted and discussed Dr. Dillon's 2008 VA examination report and Dr. Vignola's September 2008 treatment note. Dr. Scharf diagnosed PTSD "caused by childhood abuse;" cognitive disorder; rule out dementia; schizoaffective disorder, depressed type; and alcohol dependence in partial sustained remission. Dr. Scharf concluded that: [the Veteran] does not have posttraumatic stress disorder caused by the verified stressor of a diving incident while in the military. He did not report fearfulness or helplessness as a result of this incident. The stressor does not meet Criteria A for PTSD. In addition, he did not report any symptoms of PTSD related to the pool incident. He seemed to exaggerate his injury. Records show that he had a 4-inch laceration and did not lose consciousness or have an altered state of consciousness. The records do not show any cognitive difficulties or diagnosis of concussion. [The Veteran] has posttraumatic stress disorder caused by his childhood abuse. The diving incident in the military did not permanently aggravate the Veteran's preexisting posttraumatic stress disorder. It is at least as likely as not that the Veteran experienced a very mild head injury at the time. His cognitive difficulties are most likely attributed to his current medical difficulties including heart problems, strokes, and breathing difficulties. A July 2010 VA treatment record diagnosed cognitive disorder, depressive disorder, and PTSD "(childhood origin-possibly exacerbated by head injury/experiences in military)." IV. Analysis The Board has reviewed the evidence of record and finds that the preponderance of the evidence is against the claim. The weight of the evidence is against a finding that the Veteran has PTSD or any other acquired psychiatric disorder due to or aggravated by service. The Board notes that the Veteran has been repeatedly diagnosed with various personality disorders. 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 (2011); 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). As an initial matter, with respect to (1) Dr. Vignola's September 2008 opinion that an in-service head injury "could cause brain injury as well as contribute to a diagnosis of PTSD;" (2) Dr. Dillon's June 2008 opinion that it is "possible" that the Veteran's cognitive disorder is related to the pool incident in service; and (3) the July 2010 VA treatment record which reported that PTSD was "poss[ibly] exacerbated by head injury/experiences in military," these opinions have minimal to no probative value. They are less probative and persuasive than the other evidence of record as they use vague language, i.e. "could" and "possibly." The Court has held that the use of such equivocal language makes a statement by an examiner speculative in nature. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative); see also Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by a physician is too speculative). It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Likewise, Dr. Dillon's June 2008 opinion which noted that "any conclusions based on causal relations [with respect to the cognitive disorder and service] would be based merely on speculation" is insufficient to support the claim. Given the other evidence of record which provides non-speculative medical opinions on these matters, the Board finds that remanding the matter for additional opinion is not required. See Jones v. Shinseki, 23 Vet. App. 382 (2010) (an examiner must provide an adequate rationale prior to concluding that an opinion could not be provided without resort to speculation.). PTSD The preponderance of the evidence is against a finding that there is an adequate in-service stressor, including the diving incident or a personal assault in service, upon which to diagnose PTSD. With respect to the personal assault claim, the Veteran's uncorroborated testimony is not sufficient to verify the stressor set forth in this case. The Board recognizes that the present case falls 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 alleges. See, e.g., Patton v. West, 12 Vet. App. 272 (1999). As noted a February 2011 letter, informed the appellant of alternative forms of evidence which may be used to corroborate the claimed stressors, such as lay statements, records from law enforcement agencies, statements from family members and statements from fellow service members or clergy. The appellant did not provide any alternative form of evidence which could be used to corroborate any claimed stressors. The appellant did not offered any detail that would permit corroboration of any personal assault. Indeed, when presented with the opportunity to provide testimony regarding the alleged in-service personal assault, no such evidence was provided. In order to be researched, incidents must be reported and documented. Cohen, 10 Vet. App. at 134. The Board further notes that the appellant has not submitted any statements from former service comrades, nor has he submitted or identified any other evidence that would corroborate the occurrence of the claimed in-service personal assault. In reaching this determination the Board has considered the guidance established in Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011) and has considered all the evidence of record in determining whether there is corroboration. Id. With respect to his other reported PTSD stressor the diving incident in May 1963, the preponderance of the evidence does not support a finding that the diving incident is an adequate stressor upon which to base a diagnosis of PTSD. Both Dr. Dillon, in the June 2008 VA examination report, and Dr. Scharf in the June 2010 examination report, conducted a mental status examination and determined that the Veteran's diving incident does not fulfill Criterion A of the PTSD diagnosis. Dr. Dillon specifically noted that the Veteran did not "describe intrusive thoughts and memories from this event that include the necessary distress directly related to the pool incident." Dr. Scarf explained that his finding was supported by the fact that the Veteran did not report symptoms like fearfulness or helplessness related to the event. The Board accepts the two VA examiners' opinions as being the most probative medical evidence on the subject, as such were based on a review of all historical records, and contains detailed rationale for the medical conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination report, and the fact that the opinion was based on a review of the applicable record, the Board finds such opinion is probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). Aggravation The Veteran argues that his PTSD, to the extent it pre-existed service, was aggravated by the pool incident wherein he received a scalp laceration. First, as no psychiatric disorder was noted upon entry, the presumption of soundness has attached and may only be rebutted by a showing, by clear and unmistakable evidence, both that a disease or injury existed prior to service and that the disease or injury was not aggravated by service. Second, the Board finds that there is no clear and unmistakable evidence that the Veteran's PTSD pre-existed service to rebut the presumption of soundness. While there is evidence that the Veteran's current PTSD is due to his childhood experiences, there is no evidence of pre-service PTSD complaint, treatment, or diagnosis. While Dr. Scharf's 2010 opinion referred to "preexisting posttraumatic stress disorder," this single record does not rise to the level of clear and unmistakable evidence. Moreover, even if it were considered to show that the Veteran's PTSD pre-existed service, Dr. Scharf concluded that "the diving incident in the military did not permanently aggravate" the Veteran's PTSD. Therefore, the Board finds the presumption of soundness is not rebutted and the Board will consider the claim based on the theory of direct service connection. Direct Service connection The preponderance of the evidence is against a finding that the Veteran's currently diagnosed PTSD is related to service. The April and July 1999 opinions of the Veteran's VA nurse practitioner in the psychiatry clinic, the June 2008 VA medical opinion of Dr. Dillon, and the June 2010 VA medical opinion of Dr. Scarf all attribute the Veteran's currently diagnosed PTSD to the physical and sexual abuse he experienced in childhood. The Board accepts these opinions of a VA treatment provider and two VA examiners as being the most probative medical evidence on the subject. The VA examiners' opinions in particular are highly probative as they were based on a review of the claims folders, and contained a detailed rationale for the medical conclusions. See Monzingo v. Shinseki, No.10-922, (Vet. App. Nov. 21, 2012). Given the depth of the examination reports, and the fact that the opinions were based on a review of the applicable record, the Board finds such opinion are highly probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). Other psychiatric disorders The record demonstrates that the Veteran has multiple psychiatric diagnoses other than PTSD, including major depressive disorder, schizoaffective disorder, adjustment disorder, a cognitive disorder, and dementia. As noted above, the Veteran was denied service connection for depression in a February 2009 rating decision and was denied claims to reopen claims for service connection for brain damage, also claimed as traumatic brain injury and brain disease with cognitive issues including memory loss, and depression as secondary to brain damage in an August 2010 rating decision. He did not initiate appeals with respect to the February 2009 and August 2010 denials. The preponderance of the evidence is against a finding that the Veteran has a psychiatric disorder other than PTSD that is related to service. The medical opinions which address etiology of the Veteran's psychiatric disorders other than PTSD provide etiologies other than service for his psychiatric disabilities, including a history of significant substance abuse, his childhood history of physical and sexual abuse, and his (nonservice-connected) medical conditions, including small vessel disease. January 1998 psychiatric consultation notes from Crook County Mental Health noted that the Veteran reported memory problems and an angry outburst where he acted out by stabbing a knife into a table and provided the opinion that "his level of functioning is further evidence of his brain injury related to a past history of substance use." The April 1999 VA mental health record attributes his chronic mood difficulties to childhood sexual and physical abuse. His adjustment disorder, diagnosed following his October 2000 period of inpatient treatment, was attributed to his current difficulty of losing his house. Dr. Doyle, one of his June 2008 VA examiners attributed his memory loss (a symptom of his diagnosed cognitive disorder) to alcohol abuse and small vessel disease. Dr. Doyle explicitly stated that his memory loss was not due to the pool incident in service when he lacerated his scalp. Dr. Scarf in 2010 likewise attributed the Veteran's cognitive difficulties to "strokes, heart problems, and breathing difficulties." Further, the medical records indicate that the Veteran's schizoaffective disorder is based on his report of hearing voices. However, an October 2000 VA psychiatrists note indicated that the Veteran did not experience true hallucinations but only described "internal dialogue." The Board accepts these opinions of a private and VA treatment provider and two VA examiners as being the most probative medical evidence on the subject. While they do not all agree on a single cause of the Veteran's psychiatric problems, none of them provide a service-based etiology for any psychiatric diagnosis. The VA examiners' opinions in particular are highly probative as they were based on a review of the claims folders, and contained a detailed rationale for the medical conclusions. See Monzingo v. Shinseki, No.10-922, (Vet. App. Nov. 21, 2012). Given the depth of the examination reports, and the fact that the opinions were based on a review of the applicable record, the Board finds such opinion are highly probative and material to the Veteran's claim. See Owens v. Brown, 7 Vet. App. 429 (1995). Service connection for a psychosis on a presumptive basis is not warranted as no psychosis was shown within one year of leaving active duty. 38 C.F.R. §§ 3.307 3.309. Lay Evidence The Veteran lacks the competence to diagnose PTSD or any other psychiatric disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Assessment of any acquired psychiatric disorder requires mental health evaluation by a clinical psychologist or psychiatrist, not lay observation. It follows that the Veteran is not competent to assert that his current psychiatric disorder is related to service. An acquired psychiatric disorder is not diagnosed by unique and readily identifiable features and does not involve a simple identification that a layperson is competent to make. The determination of both the diagnosis and etiology of any acquired psychiatric disorder must be made by a mental health professional, pursuant to the Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating and determining causal connections for psychiatric conditions. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. To the extent that the Veteran has asserted that his symptoms of a psychiatric disorder have been continuous since service, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a psychiatric disorder after service separation. Numerous health care providers have described him as an "inconsistent historian" (see October 10, 2007 VA treatment record) and a "questionable historian" (see treatment record signed November 20, 2000 by VA psychologist). Such surely discredits any present (more recent) account that relies on memory. Indeed, the Veteran's more recently-reported history of continued symptoms of a psychiatric disorder since active service is inconsistent with the other lay and medical evidence of record. He now asserts that his disorder began in service. However, in the more contemporaneous medical history, he gave at the service separation examination, as noted by the June 2008 scars examiner, he denied any history of memory loss as well as any history of depression or excessive worry and denied nervous trouble of any sort. Had he been experiencing psychiatric problems while in service, one would believe it would have been reported when presented with that opportunity. Weight is also given to the Veteran's service separation examination report, which reflects that the Veteran was examined and his psychiatric system was found to be clinically normal. His in-service history of symptoms at the time of service separation is more contemporaneous to service, so is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to his subsequent assertion years later). The Board thereby concludes that his assertion of continued symptomatology since active service, while competent, is not credible. Any account reporting continuous manifestation of psychiatric symptoms since service is self-serving. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the appellant's statements, it may consider whether self-interest may be a factor in making such statements). Other than the speculative medical opinions noted above relating PTSD or other psychiatric disorders to service, there is no competent evidence of record linking any current psychiatric disorder to service. For all of these reasons and bases, the Board finds the probative, i.e., competent and credible, medical and other evidence of record does not establish the Veteran has an acquired psychiatric disorder, to include PTSD, that is attributable to his military service. Although he is entitled to the benefit of the doubt where the evidence is in approximate balance, this benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against his claim. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Service connection for an acquired psychiatric disorder, including PTSD, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs