Citation Nr: 1306392 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 07-27 288 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from December 1966 to August 1968, and from February 1981 to December 1982. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a May 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, that continued the denial of service connection for PTSD. In October 2009, the Veteran testified at a Board hearing held at the RO. A transcript of the hearing is of record. In a January 2010 Board decision and remand, the Board recharacterized the issue on appeal as whether new and material evidence had been submitted to reopen a claim of entitlement to service connection for a nervous disorder, to include PTSD. This was based on a prior denial of service connection for a nervous disorder on file in February 1988, and is pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the veteran cannot be held to a medical level of understanding of differences between psychiatric disorders, so that his claim for one also must be considered a claim for any other psychiatric disability whose presence is supported by the record). The Board reopened the claim for service connection for a nervous disorder, to include PTSD, and remanded the underlying merits of the service connection claim for further development. In this regard, the Board directed that further stressor clarification and verification be attempted, that outstanding service treatment and personnel records be obtained, and that the Veteran undergo a VA psychiatric examination. Pursuant to the RO's request in January 2010 to the Veteran for stressor clarification and to the National Personnel Records Center (NPRC) for the Veteran's personnel records, the RO received a stressor statement from the Veteran in February 2010 and a response from the NPRC in June 2010. In addition, the Veteran was afforded VA psychiatric examinations in October 2010 and May 2011. Thus, there has been substantial compliance with the Board's January 2010 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Review of Virtual VA reveals no documents pertinent to this appeal. In November 2011, the Board sought a medical expert opinion as set forth in VHA Directive 2010-044 dated September 29, 2010. An opinion was received in February 2012 with an addendum in May 2012. In June 2012, the appellant was provided a copy of the opinion and given 60 days to review the medical opinion and send any additional evidence or argument in support of his claim. The appellant did not thereafter submit additional information or evidence in support of his claim. FINDINGS OF FACT 1. The weight of evidence shows that the Veteran does not have PTSD. 2. The Veteran's current psychiatric disability, diagnosed as major depressive disorder, generalized anxiety disorder and substance abuse, has been aggravated by his service connected back disability, right and left knee disabilities and diabetes mellitus, type II. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304(f) (2012). 2. The criteria for service connection for a psychiatric disability other than PTSD, diagnosed as major depressive disorder, generalized anxiety disorder and substance abuse, based on aggravation, have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), defines the obligations of VA with respect to the duty to assist and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. First, VA has a duty to notify the Veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103 (West 2002); 38 C.F.R. § 3.159(b) (2012). Second, VA has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). The decision of the United States Court of Appeals for Veterans Claims (Court) in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. With respect to service connection for a psychiatric disability other than PTSD, as discussed in detail below, sufficient evidence is of record to grant the matter on appeal. Therefore, no further notice or development is needed with respect to this matter. With respect to service connection for PTSD, a VCAA letter was issued to the Veteran in March 2005. As this was prior to the May 2005 rating decision on appeal, the timing of the notice complies with the express requirements of the law as found by the Court in Pelegrini. On March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Dingess/Hartman, supra. In this case, the Board finds that the appellant was notified of the disability rating and effective date elements in a June 2007 Statement of the Case. The Board also finds that all necessary assistance has been provided to the appellant including requesting pertinent VA and private medical records as well the appellant's records from the Social Security Administration (SSA). In addition, the appellant was afforded a number of VA examinations and a VHA opinion was obtained. The Board finds that the examination findings were based on a thorough examination of the Veteran as well as a review of his claims file, to include his medical history and complaints, and contain adequate opinions in which to evaluate his service connection claim. Therefore, the Board finds that the VA examination reports and VHA opinion are adequate for rating purposes and new examinations and/or opinions are not required. See Barr v. Nicholson, 21 Vet. App. 303, 311 (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Also, the appellant was provided with the opportunity to testify at a Board hearing which he attended in October 2009. Under these circumstances, the Board finds that VA has fulfilled its duty to notify and assist the appellant in the claim under consideration and that adjudication of the claim at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the appellant. See, e.g., Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The appeal is now ready to be considered on the merits. II. Facts The Veteran's service treatment records show extensive treatment for instability and pain in the right and left knees and for chronic low back pain. They are devoid of complaints or treatment of a psychiatric nature with the exception of an October 1981 record assessing the Veteran as having a reaction to the flu shot and being under a lot of stress, and a July 1982 record containing an impression of mild, borderline hypertension, probably secondary to situational anxiety. A June 1982 Medical Board examination report shows a normal clinical psychiatric evaluation. Records show that the Veteran was placed on TDRL (Temporary Disabled Retired List) in December 1982 due to his knee disabilities and was permanently retired from service in April 1984 due to his knees. On file is a VA Social Work History and Assessment dated in June 1985 shows that the Veteran was experiencing problems with numbness on the left side which may be related to a cervical injury. He said he has also been told his problems may be in his head and that he was willing to work with the problem to feel better, whether it be with a psychiatrist or other kind of specialist. He also admitted that he was living in an environment that was causing enough anxiety to produce his present symptoms. A VA intake data sheet from the mental health clinic completed in November 1987 shows that the Veteran presented with a problem of getting shaky inside and in his hands every time he gets "flustered" which happened frequently. He was noted to be self conscious, irritable and unable to relax. He was noted to be like that for the last five to six years and had recently noticed a worsening in his condition. He said he felt lonely and had lived alone since 1986. Findings revealed that he did not have clinical depression. He was assessed as having generalized anxiety disorder. VA outpatient records in November 1987 show that the Veteran was being seen for the first time in the Mental Health Clinic and had been revered by the medical clinic. He was noted to have back and knee problems and appeared "over anxious". He was also noted to have no previous history of psychiatric care. Findings revealed that he was anxious and irritable with a poor self image and a fear of rejection. He was also noted to isolate himself and then feel lonely. He was diagnosed as having generalized anxiety disorder and prescribed Valium, 5 milligrams, twice daily. It was also noted that he was to be followed in the mental health clinic. In December 1987, the Veteran filed an informal claim for service connection for a nervous disorder. He said he recalled being treated for this at a VA medical facility in 1983. VA records from the mental health clinic in December 1987 and February 1988 reflect diagnoses of generalized anxiety disorder and note that the Veteran was improving with cognitive therapy. A February 1993 VA record from hematology/oncology shows that the Veteran had erythrocytosis probably secondary to stress of hypertension and arthritic pain. A March 1995 VA record from Physical Medicine and Rehabilitation Services notes that the Veteran continued to have chronic pain which would cause "crying" when severe. An April 2001 VA outpatient record shows that the Veteran had a negative depression screen. By rating decision dated in March 2003, the RO granted service connection for the following disabilities: status post medial and lateral meniscectomies, right knee, with instability, rated 20 percent disabling; medial instability, left knee, rated 10 percent disabling; hypertension rated 10 percent disabling; and chronic low back pain with traumatic hypertrophic changes, thoracic spine, rated 10 percent disabling. In March 1987, the RO increased the Veteran's rating for his back disability to 20 percent disabling. A VA social work note in October 2003 reflects the Veteran's report that his girlfriend felt he was becoming more verbally abusive and she was concerned that he could become violent. The Veteran reported that he loses his temper and is irritable. VA records in 2003 and 2004 show treatment for anxiety state and depressive disorder. Also VA mental health clinic entries in August 2003 and July 2004 show that the Veteran had positive PTSD screens. In a statement received in August 2004, the Veteran reported stressful events he experienced while serving in Vietnam. He also reported that he has been "jumpy[,] goosey and paranoid since Vietnam". He said after 35 years the nightmares, flashbacks and memories had not gone away. He also said that he scared his wife and son as well as himself with his anger outbursts. Records show that the Veteran as seen at a VA Agent Orange clinic in September 2004 where he reported depression, anxiety, flashbacks, nightmares and anger. He was assessed as having anger and anxiety and was given a trial of Zoloft in place of amytryptyline. A VA psychiatric note in October 2004 shows that the Veteran had not been seen previously since March 2004. The Veteran reported improvement with his newly prescribed sertraline and requested an increase in dosage. He also "rambled on incessantly" about his personal problems at the time. He was assessed as having depressive disorder, not otherwise specified. A VA social work note in October 2004 shows that the Veteran was being seen for his anxiety and was under a lot of stress and was losing control of his temper because of his family. He reported caring for his wife who was on bed rest following foot surgery and was also caring for his ill mother-in-law. In addition, he was experiencing problems with his 13 year old son. In November 2004 the Veteran underwent a VA psychology consult. The examiner gave him a clinical diagnoses of depression, anxiety state and rule out personality disorder. The examiner opined that given the Veteran's longstanding mental health difficulties, the presence of neglect/abuse by family, reared in children's home, military combat, work underachievement/difficulties, tensions with others, distant substance abuse, etc., a preliminary personality disorder was suggested. He also reported that per a November 2002 psychological report, the Veteran's psychologist did not find that the Veteran met the criteria for PTSD. The Veteran reported in a statement dated in May 2005 that his stressor involved falling 20 feet which terrified him. He said he had nightmares and flashbacks frequently and a morbid fear of falling. He also reported that his depression and anxiety were secondary to his service-connected back pain and pain from his service connected knee condition. Various VA outpatient records in 2005 and 2006 reflect diagnoses of depression NOS (not otherwise specified), anxiety NOS, PTSD, rule out PTSD and personality disorder (NOS). A VA psychology group treatment record shows that a goal of treatment for the Veteran was improvement of PTSD symptoms (emotional trauma secondary to childhood abuse and military experiences. VA psychology treatment records show that the Veteran's therapy for anxiety disorder NOS was considered terminated in January 2007 after the Veteran missed two therapy sessions without providing notice, but that treatment resumed in June 2007 after the Veteran returned requesting therapy. In June 2007, the Veteran underwent a VA PTSD examination conducted by a psychologist. The Veteran reported that his stressor involved being insulted by a prostitute in Cam Rahn Bay. He said that he strangled her in a fit of rage and did not tell anyone about it. He also said he landed in Long Bihn during a mortar or rocket attack of the airfield from a distance he saw a GI get hit by shrapnel and killed. He denied that falling from a ladder was a stressor. The examiner noted that the Veteran had no problematic effects from alcohol use. During the evaluation, the examiner remarked that some of the Veteran's statements were inconsistent and his descriptions of angry outbursts seemed to be overly dramatized. After examining the Veteran and reviewing his claims file, the examiner found that the Veteran did not meet the DSM-IV criteria for PTSD. He diagnosed the Veteran as having mood disorder NOS, and personality disorder, mixed (primary). Records from SSA include VA outpatient records. These records include a Social Work Note in September 2002 at which time the Veteran reported that he could barely move around due to arthritis and back problems. He said he was used to working long hours and was beginning to realize he could no longer work. He said he was going to quit his job at a pizza delivery establishment and apply for SSA benefits. VA outpatient records also show that the Veteran received psychological treatment from October 2002 to December 2002. A November 2002 psychological record states that the Veteran did not meet the full intent of the DSM-IV PTSD, and his Axis I diagnosis was more consistent with generalized anxiety and depressive disorder. SSA records show that the Veteran was awarded disability benefits effective in September 2002 due to severe impairments consisting of cervical strain, dorsolumbar strain, chronic obstructive pulmonary disease, degenerative arthritis of the knees, hypertension, depression and anxiety disorder. In his substantive appeal dated in August 2007, the Veteran described his stressor as falling 20 feet while dismantling a building in Cam Rahn Bay. He said the intense fear or falling and powerful impact has bothered him ever since. VA psychiatry notes in October 2008 and May 2009 indicate that the Veteran had service connected PTSD, but was not currently rated for it. The October 2008 note indicates that the Veteran's trauma may not be the most severe and he may not actually have been in combat. The physician said the Veteran's military occupational specialty was not discussed nor was his trauma discussed. VA individual psychotherapy records in 2008 and 2009 reflect diagnoses of mood disorder due to generalized medical condition (chronic pain), PTSD, and rule out personality disorder. At a Travel Board hearing in October 2009, the Veteran testified that a stressful event occurred in service when he fell 20 feet from on top of a mess hall that had collapsed requiring treatment for a knee injury on several occasions. He said he was put on a profile after the injury and never returned to his job. He reported reliving the event in his dreams. He also said that sometime following his service discharge he rejoined the Army and fell again in basic training severely reinjuring the knee. He said following his knee injury he could no longer perform his regular duties and ran a beer barn and was constantly drunk. He said he began seeking VA medical treatment right after he got out of service in 1982. The Veteran's spouse and son submitted statements in February 2010 reporting that the Veteran experienced flashbacks of Vietnam which made him violent towards his spouse. They said his son had to intervene to keep the Veteran from hurting his spouse. In a statement dated in April 2010, the Veteran said that his stressor was falling 20 feet off of a roof. He said the fall was terrifying and has bothered him ever since. At a VA psychiatric examination in October 2010, the Veteran said he wasn't sure if he had ever sought mental health care prior to the Community Based (CB) Outpatient Clinic in 2002. He said he thinks he has PTSD because his wife wakes him up at night with his hands around her neck. He reported having a recurrent dream where he sees Vietnamese in black pajamas. He also reported that he heard enemy fire but did not fire and was not fired upon. He reported having a chaotic and violent childhood that involved alcoholic parents who were physically and verbally abusive. He said he had a prior drinking problem, but denied the use of alcohol/drugs as a minor "other than an occasional alcoholic beverage." He reported that at the age of 4 he went to live in a children's home for 8 or 9 nine years and reported sexual abuse while at the home. He acknowledged that his military occupational specialty in service was a cook, but asserted that he only cooked for 45 minutes in Vietnam before being switched to driving a fork lift. He said he received small arms and received mortar shelling. He said when he first arrived in Vietnam, the landing strip was being mortared so the plane had to stay in the air. He also reported witnessing a friend's death and an enemy's death, but upon closer inspection, the Veteran denied actually seeing a dead friend or enemy, but rather had heard about the incidents. He denied witnessing a child's death, a female's death, a friend's death, an execution, inhumane treatment, or a friendly fire incident. He denied any disciplinary problems in service. He reported falling 20-30 feet from a mess hall and was sent to sick hall, but was not hospitalized. He described his military experience as "extremely stressful" He denied any traumatic experiences during his re-enlistment period beginning in February 1981. The examiner concluded that the Veteran did not appear to meet the criteria for a diagnosis of PTSD and was not reporting sufficient trauma to meet criterion A. He summarized by stating that the Veteran's profile was not consistent with a diagnosis of PTSD. He went on to diagnose the Veteran as having PTSD (non-military related), mood disorder due to general medical condition (chronic pain/non-military related), anxiety disorder (non-military related) and personality disorder (non-military related). The examiner relayed that it was felt that the Veteran's occupational and interpersonal problems were the result of both personality disorder and unresolved childhood. The examiner went on to state that the Veteran's diagnoses of child PTSD, anxiety disorder NOS, personality disorder NOS, and mood disorder due to chronic pain were not seen as caused by or related to any military experience. The examiner reported that the Veteran did not have military-related PTSD. On file are VA individual psychological treatment notes and psychiatric notes dated in January, February and March 2011. A VA individual psychological outpatient treatment record in March 2011 shows that the Veteran had recently transferred his physical health care from the Marietta CB outpatient clinic to the Athems CB outpatient clinic due to a "recent exacerbation [of] long-standing tensions". He was diagnosed as having mood disorder due to general medical condition (chronic pain) and PTSD (childhood, military). A March 2011 VA psychiatric record reflects diagnoses of anxiety disorder and some symptoms of PTSD due to some trauma in Vietnam, although a full evaluation was not done at that time. In May 2011 the Veteran underwent a VA psychological evaluation. The examiner reported that the Veteran's Capri records were reviewed, but his claims file did not arrive at the time of the examination and was not reviewed. The Veteran admitted to being depressed as a kid, but denied being angry. He said after service he had trouble keeping a job and had lots of suicide thoughts. He reported that he still drinks alcohol, but it was a serious problem from 1995 to 2003. He said he used different drugs in the past including heroin and within the past 10 years has used pot, alcohol and coke, but had not used pot in the past few years. He was noted to have reported on a history form having 12 drinks in the past 30 days. Psychological testing conducted at that time was noted to most likely be invalid due to extreme exaggeration and embellishment of problems and symptoms, including a number of different psychiatric symptoms and disorders which the Veteran was noted to have never experienced. The examiner further noted that previous psychological assessment documented in the medical records also included exaggeration and invalid test results. He described the Veteran as a chronically disabled man as a result of personality and physical problems. He opined that the Veteran's psychological and personality problems were rooted in early childhood abandonment and abuse by care-takers, including his own parents. He said there was no information presented by the Veteran or contained in the medical reports which linked his current mood and personality disturbance to military service over 30 years earlier. He diagnosed the Veteran as having a pain disorder associated with both psychological factors and a medical condition and a personality disorder NOS (non-military, dating back to childhood). He further noted that there was no evidence that the Veteran's current emotional distress was related to a medical condition from over 30 years ago when he was in service. In an addendum opinion in July 2011, the May 2011 VA psychological examiner reported that while the claims file had not been reviewed at the time of the examination of the Veteran, it arrived the following day and was reviewed in its entirety prior to the completion of the examination report. He said he agreed with the prior VA examiner's opinion in October 2010 that the Veteran's current emotional limitations were due to emotional, physical and personality disturbance unrelated to his military experiences; but rather, it was traumatic childhood and adolescent events including childhood sexual, physical, and emotional abuse, as well as early abandonment by his parents that has been responsible for his chronic problems during adulthood. He noted that there was no medical information that the Veteran experienced a PTSD reaction soon after a traumatic incident in Vietnam. In an August 2011 statement, the Veteran said that his treating physiatrist and psychologist have provided diagnoses of PTSD due to service. In November 2011, VA sought a VHA expert opinion to clarify the Veteran's psychiatric diagnoses and determine whether such diagnoses were caused or aggravated by the Veteran's active duty service. The RO received a reply in February 2012 by a physician who stated that without further verifiable substance abuse information, it was not possible to provide an opinion regarding the Veteran's psychiatric diagnoses at that time. She said that all of the substances the Veteran admitted to having used were known to either precipitate do novo or at least aggravate pre-existing mood and/or anxiety disorders. She added that his record showed various inconsistencies in his answers to substance abuse screening efforts. VA made another attempt to obtain a VHA expert opinion in March 2012. After reviewing the Veteran's claims file, the VHA examiner reported that it was impossible to be "reliably specific" in arriving at a psychiatric diagnoses without conducting a personal diagnostic interview with the Veteran, but that the Veteran could be reasonably diagnosed from the record as having the non-PTSD conditions of depressive disorder NOS, anxiety disorder NOS, and substance abuse NOS. As to the question of a nexus to service, the examiner opined that it was at least as likely as not that each disorder had been aggravated beyond the normal progress of the disorder by service-connected disability. The examiner said that it was impossible to be precise in regard to the degree to which these conditions have been aggravated beyond the degree that would be expected in the absence of the additional influence of service-connected disabilities. Nonetheless, he went on to note that the presence of chronic back pain and the discomforts, functional impairments, and stresses associated with several of his other service-connected physiological conditions (right and left knee conditions and diabetes) would be, in his opinion, more than 50% likely to exacerbate these psychiatric conditions beyond their baseline status. He explained that it would be unusual for such physiologic comorbidities to not worsen the course of the psychiatric conditions under consideration. He added in the absence of a direct diagnostic interview, his conclusion must be, at least to some extent, conjectural, but was one in which he had some degree of confidence in light of his experience with patients similar to the Veteran in question. III. Analysis Law and Regulations 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; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F. 3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service connected condition. 38 C.F.R. § 3.310. To establish secondary service connection, three elements must be satisfied: (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection is possible when a service connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to incorporate the Court's decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service connected disability. 38 C.F.R. § 3.310(b). In this case, the Veteran applied for service connection prior to the effective date of the amendment. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran because it does not require the establishment of a baseline before an award of service connection may be made. Also, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including psychoses, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In addition, there are particular requirements for establishing PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F. 3d 1343, 1347 (Fed. Cir. 2010). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD varies depending upon whether the veteran engaged in "combat with the enemy." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). If VA determines the 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 was found to be "satisfactory," i.e., credible and "consistent with circumstances, conditions or hardships of service." See 38 U.S.C.A. § 1154(b);38 C.F.R. § 3.304(f); Zarycki, 6 Vet. App. at 98. Prior to a recent amendment to the PTSD regulation, discussed below, where the claimed stressor was not related to combat, a veteran's lay testimony alone was not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record was required to contain service records or other corroborative evidence which substantiated or verified the Veteran's testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Effective July 13, 2010, 38 C.F.R. § 3.304(f) was amended to reduce the evidentiary burden of establishing a stressor when it is related to a fear of hostile military or terrorist activity. See 75 Fed. Reg. 39843 -01 (July 13, 2010), codified at 38 C.F.R. § 3.304(f)(3) (2012). The amendment provides that, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity, and a VA or VA contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran's service and there is no clear and convincing evidence to the contrary. Id. "Fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The list of examples of such an event or circumstance specifically includes a threat to the physical integrity from an actual or potential improvised explosive device. The Board notes initially that, although the Veteran served during a period of war, the evidence does not suggest, and the Veteran does not contend, that he engaged in combat with the enemy, or that his claimed PTSD is related to combat. Therefore, neither the combat provisions of 38 U.S.C.A. § 1154 (West 2002) nor the rule relating to combat stressors are applicable. Direct service connection may be granted only when a disability was incurred or aggravated in the line of duty, and not the result of a veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his or her abuse of alcohol or drugs. 38 U.S.C.A. § 105, 38 C.F.R. § 3.301(a). An alcohol or drug abuse disability acquired secondary to, or as a symptom of, a service connected disability can be service connected for compensation. Allen v. Principi, 237 F. 3d 1368, 1376, 1381 (Fed. Cir. 2001) (explaining that 38 U.S.C.A. § 1110 (West 2002)) does not preclude compensation for an alcohol or drug abuse disability acquired on a secondary service connection basis). A veteran must adequately establish that, through clear medical evidence, an alcohol or drug abuse disability is secondary to or caused by a primary service connected disorder and not due to willful wrongdoing. Id. Compensation is precluded in only two situations: (1) for primary alcohol abuse disabilities; and (2) for secondary disabilities (such as cirrhosis of the liver) that result from primary alcohol abuse. Id. At 1376. The term "primary" means an alcohol abuse disability arising during service from voluntary and willful drinking to excess. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Discussion In this case, the Veteran asserts that he suffers from PTSD as a result of stressful events in service. He also asserts that his depression and anxiety are secondary to his service-connected back pain and pain from his service connected knee condition. In regard to PTSD, after considering the evidence of record in light of the governing criteria, the Board finds that the first essential element for establishing service connection for PTSD - a diagnosis of PTSD - has not been met. Though there is both favorable and unfavorable evidence on this point, the Board finds that the weight of probative evidence is against a finding that the Veteran has PTSD due to service. The unfavorable evidence includes a VA psychological report in November 2002, a VA PTSD examination report in June 2007, and a VA PTSD examination report in October 2010, all concluding that the Veteran did not meet the DSM-IV criteria for PTSD. In addition, there is a June 2011 VA addendum opinion given by a May 2011 examiner stating that there was no medical information that the Veteran experienced a PTSD reaction soon after a traumatic incident in Vietnam, and an expert VHA opinion of May 2011 stating that the record showed that the Veteran had non-PTSD conditions. All of these opinions were based on consideration of the Veteran's reported stressors, a review of his claims file, and, with the exception of the VHA opinion, on an evaluation of the Veteran. The favorable evidence of record consists of VA outpatient notes from 2005 through 2011, some of which reflect diagnoses of PTSD or rule out PTSD. Some records relate the PTSD diagnosis to the Veteran's childhood, others to both his childhood and his military service. However, the records that relate the Veteran's PTSD, in part to his military service, do not indicate the basis of the diagnosis or contain a discussion of the inservice stressors that were considered. Indeed, VA outpatient psychiatry notes in October 2008 and May 2009 while noting that the Veteran had "service connected PTSD, but was not currently rated for it", also note that the Veteran's military occupationally specialty was not discussed nor was his trauma discussed. In short, the Board finds that the November 2002, June 2007, October 2010, June 2011 and May 2011 VA/VHA examiner's opinions to be the most persuasive with respect to a PTSD diagnosis. As noted, unlike the VA outpatient records which merely reflect, in some records, diagnoses of PTSD, the VA opinions negating a PTSD diagnosis were based on consideration of the Veteran's reported stressors, a review of his claims file, consideration of the DSM-IV criteria and, with the exception of the VHA opinion, on an evaluation of the Veteran. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (The probative value of medical evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches). Also, the weight to be attached to medical evidence is within the province of the Board. Id. The Board has not overlooked the Veteran's statements to the effect that he has PTSD. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). In this regard, the Veteran reported at the PTSD examination in October 2010 that he thought he had PTSD because he wakes up at night with his arms around his wife's neck. While lay witnesses are competent to describe experiences and symptoms that result therefrom, because laypersons are not trained in the field of medicine, they are not competent to provide opinions relating to the diagnosis or etiology of diseases or disabilities. Id. Therefore, the Board will give more credence to the medical evidence found in the record than the lay assertions with respect to medical diagnoses and/or etiology thereof. For the reasons provided above, the Board finds that the weight of medical evidence shows that the Veteran does not have PTSD. Consequently, further analysis as to whether the remaining criteria under 38 C.F.R. § 3.304(f) have been met is not warranted. Notwithstanding the Board's finding above with respect to PTSD, postservice medical records show that the Veteran has been diagnosed as having various psychiatric disabilities, to include depression, anxiety, adjustment disorder with depressed mood, and dysthymic disorder. After reviewing the evidence in its entirety, the Board finds that the evidence supports the grant of service connection for major depressive disorder and anxiety disorder as well as his recently diagnosed substance abuse, by aggravation. The Veteran is presently service-connected for status post medial and lateral meniscectomies, right knee, with instability, rated 20 percent disabling; traumatic arthritis, right knee, rated 10 percent disabling; early osteoarthritis, left knee, rated 10 percent disabling; hypertension rated 10 percent disabling; diabetes mellitus, type II, rated 10 percent disabling, and chronic low back pain with traumatic hypertrophic changes, thoracic spine, rated 20 percent disabling. As noted, a VHA examiner in May 2012 reported that the Veteran could be reasonably diagnosed as having the non-PTSD conditions of depressive disorder NOS, anxiety disorder NOS, and substance abuse NOS. He went on to opine that with respect to these diagnoses, it was at least as likely as not that that each disorder had been aggravated beyond the normal progress of the disorder by service-connected disability. He explained that the presence of chronic back pain and the discomforts, functional impairments, and stresses associated with several of his other service-connected physiological conditions (right and left knee disabilities and diabetes) would be, in his opinion, more than 50% likely to exacerbate these psychiatric conditions beyond their baseline states. This is indeed consistent with numerous VA outpatient records diagnosing mood disorder due to generalized medical condition (chronic pain) as well as the Veteran's assertion in May 2005 that his depression and anxiety are secondary to his service-connected back pain and pain from his service connected knee condition. As far as substance abuse, this diagnosis was not made until the VHA examiner's review in May 2012, but the Veteran's reports of drinking problems are noted in various records to include the October 2010 and May 2011 VA examination reports. The VHA examiner in November 2011 stated that without further verifiable substance abuse information, it was not possible to provide an opinion regarding the Veteran's psychiatric diagnoses at that time. She said that all of the substances the Veteran admitted to having used were known to either precipitate do novo or at least aggravate pre-existing mood and/or anxiety disorders. The subsequent review by the VHA examiner in May 2012 supports substance abuse by aggravation. In light of the evidence outlined above and the lack of any evidence or opinion to the contrary, the Board finds that the weight of evidence favors the grant of service connection for a psychiatric disability other than PTSD, diagnosed as major depressive disorder, anxiety disorder and substance abuse, by aggravation of the Veteran's service connected back, right and left knee disabilities and diabetes mellitus, type II. 38 C.F.R. § 3.310. ORDER Service connection for PTSD is denied. Service connection for a psychiatric disability other than PTSD, diagnosed as major depressive disorder, anxiety disorder and substance abuse, is granted based on aggravation. ____________________________________________ Cheryl L. Mason Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs