Citation Nr: 1306459 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 08-11 244 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Veteran and Spouse ATTORNEY FOR THE BOARD L. Durham, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to December 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision issued by the VA RO, in St. Petersburg, Florida, which, in pertinent part, determined that new and material evidence had not been received to reopen a claim of entitlement to service connection for PTSD. By a subsequent November 2008 rating decision, the RO reopened the Veteran's previously denied claim of service connection for PTSD and denied the claim on the merits. An April 2009 rating action continued the denial. The Veteran provided testimony at a hearing before the undersigned Veterans Law Judge in February 2010. A transcript of this hearing has been associated with the Veteran's VA claims folder. This case was previously before the Board in July 2010, at which time the Board, among other things, concurred with the RO's determination that new and material evidence had been received to reopen the previously denied claim. However, the Board also determined that additional development was required for adjudication of the underlying service connection claim. Therefore, the claim was remanded for such development to include a new VA medical examination that addressed the nature and etiology of the Veteran's claimed acquired psychiatric disorder. Such an examination was accomplished in January 2011, and all other development directed by the Board's July 2010 remand was accomplished. Accordingly, a new remand was not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). Despite the foregoing, there was a change in law regarding claims of service connection for PTSD that was effective subsequent to the prior July 2010 remand. As such, the Board remanded this issue again in March 2012 in order to conduct development in compliance with this change of law. All development directed by the Board's March 2012 remand was accomplished, and this issue is now back before the Board for consideration. See Stegall, supra. The Board notes that the Veteran submitted additional evidence after the most recent supplemental statement of the case (SSOC) was issued with respect to this issue. As this evidence was of record and therefore considered by the RO in the October 2012 supplemental statement of the case, no additional action is required with respect thereto. The Board notes that the Veteran submitted a statement dated in June 2012 requesting that his current fiduciary be removed. It is unclear from the evidence of record whether this request has ever been addressed. Therefore, the Veteran's claim to have his fiduciary removed has been raised by the record, but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDING OF FACT The most probative medical evidence of record does not reveal that the Veteran has a diagnosis of PTSD related to an in-service stressor or a diagnosis of an acquired psychiatric disability that is shown to be etiologically related to a disease, injury, or event in service. CONCLUSION OF LAW Service connection for an acquired psychiatric disorder, to include PTSD, is not warranted. See 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim for service connection, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. A VCAA letter dated in May 2007 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was aware that it was ultimately his responsibility to give VA any evidence pertaining to the claim. This letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Additionally, this letter described how appropriate disability ratings and effective dates were assigned. The Board also concludes VA's duty to assist has been satisfied. The Veteran's available service treatment records and relevant VA and private medical records are in the file. All records identified by the Veteran as relating to this claim have been obtained, to the extent possible. The Board finds that the record contains sufficient evidence to make a decision on the claim. VA has fulfilled its duty to assist. With regard to claims for service connection, the duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). The Veteran was provided multiple VA examinations for his acquired psychiatric disorder, to include PTSD, claim most recently in January 2011. The examiner reviewed the claims file, conducted the appropriate diagnostic tests and studies, and noted the Veteran's assertions. This same examiner then provided another opinion on this matter in March 2012. As such, the Board finds these examination reports and opinions to be thorough, complete, and sufficient upon which to base a decision with regard to this claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). With respect to the February 2010 Board hearing, the Court of Appeals for Veterans Claims held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ noted the current appellate issue at the beginning of the hearing, and testimony concerning the Veteran's contentions and treatment history was obtained. Following the hearing, the case was remanded in order to obtain additional VA treatment records and to afford the Veteran VA examinations. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2012). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(1) (2012); see also, 38 U.S.C.A. § 1154(b) (West 2002). Otherwise, the law requires verification of a claimed stressor. Where a determination is made that the Veteran did not "engage in combat with the enemy," or the claimed stressor is unrelated to combat, the Veteran's lay testimony alone will 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 must include service records or other credible evidence that supports and does not contradict the Veteran's testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). In recent years, the regulations governing PTSD have been amended, effective July 13, 2010. 75 Fed. Reg. 39843-52 (July 13, 2010). Specifically, this amendment eliminates the requirement for corroborating that the claimed in-service stressor occurred if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, provided that the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. Id. The Veteran is seeking entitlement to service connection for an acquired psychiatric disorder, to include PTSD, as a result of his Vietnam service. A review of the service treatment records reveals that the Veteran was noted in a 1967 service treatment record from the neuropsychiatric section as having no apparent mental illness. The claims file contains no complaints, treatment, or diagnoses of a psychiatric disability of any kind or PTSD. As previously noted by the Board in July 2010, a copy of the Command Chronology (from December 1, 1967 to December 31, 1967) of the 1st Bridge Company, 7th Engineer Battalion shows the Veteran's unit was attacked on several occasions with small arms fire, mortar, rockets, and command detonated mines in Vietnam. The Board also noted that the Veteran served in Vietnam from December 7, 1967 to January 13, 1968. Therefore, the Board found, in pertinent part, that the Command Chronology was evidence of a verified in-service stressor. Despite the foregoing, the Board also found that the evidence of record was unclear as to whether the Veteran did, in fact, have PTSD or a different acquired psychiatric disorder, and whether such a disorder was causally related to his active service. At a February 2008 VA examination, the examiner provided a diagnosis of depressive disorder, NOS and stated that the Veteran did not meet the criteria for a diagnosis of PTSD. The examiner did not provide any opinion as to whether or not the Veteran's depressive disorder was related to his period of military service. Further, at an October 2008 VA examination, this same examiner provided diagnoses of depressive disorder, NOS and cognitive disorder, NOS. This examiner was unable to determine whether or not the Veteran met the criteria for a diagnosis of PTSD without resorting to mere speculation because the Veteran was unresponsive to questioning. The examiner was also unable to provide an opinion as to whether the currently diagnosed depressive and cognitive disorders were related to the Veteran's military experience without resorting to mere speculation because there was insufficient information to form such an opinion. This same examiner conducted another VA examination in September 2009. At the September 2009 VA examination, the examiner noted that the Veteran again did not respond directly to questions, instead repeating "Charlie...kill, Charlie." The examiner noted that this pattern appeared to be at least, in part, volitional. The Veteran was able to respond to questions and provide information to the audiologist in the compensation and pension examination following this examination. The examiner noted, that because of the Veteran's refusal/inability to provide information, the undersigned ask the Veteran's wife to join the interview. The examiner determined that he could not give an opinion about whether the Veteran met the criteria for PTSD using the CAPS and SCID. The Veteran would not respond to questions, other than to repeat either "Charlie" or "kill" on occasion. His wife provided the information in this interview with the exception of background information obtained from the records. The wife's statements and the background information were insufficient to determine whether the Veteran met the criteria for PTSD. The examiner noted that, while at least some of the Veteran's cognitive impairment appears to be malingered, he could not give a definitive opinion that the Veteran was without some cognitive impairment. Therefore, it is at least as likely than not that the Veteran's cognitive disorder, NOS (provisional diagnosis) prevents the Veteran from managing VA benefits. The examiner assigned an Axis I diagnosis of "Malingering. Rule Out (consider) Cognitive Disorder NOS. Cocaine Dependence, in reported full sustained remission." The examiner noted that the Veteran's dramatic presentation at this examination was in sharp contrast with his presentation in the compensation and pension examination following this examination. In audiology examination, the Veteran did respond to some questions in a relevant and coherent manner. Therefore, the Veteran does have the ability to provide at least some relevant information and his attempt to present as incapable is most likely attributable to an effort to appear impaired so that that he can receive service connection for a psychological condition. The diagnosis of cognitive disorder was assigned in the October 2008 VA examination. However, the current diagnosis of cognitive disorder NOS has the qualifier "rule out" because some or all of the Veteran's observed cognitive impairment appears to be malingered. The Veteran has a history of cocaine dependence and this is in reported remission. The examiner concluded by noting that, because the Veteran apparently did not cooperate with the examination, the examiner would have to resort to mere speculation to opine if he meets the criteria for PTSD. However, VA treatment records obtained during the course of this appeal revealed diagnoses of PTSD, and acquired psychiatric disorders other than PTSD, including severe psychosis, anxiety disorder, not otherwise specified (NOS), delirium, dementia and depression, NOS. In view of the foregoing, the Board remanded the case in July 2010, in part, for a new VA medical examination to determine whether the Veteran meets the criteria for a diagnosis of PTSD, and if so, what stressor(s) supported the diagnosis. If the examiner found that the Veteran did not meet the criteria for a diagnosis of PTSD, the examiner was to specify the criteria for the diagnosis that were not met. With respect to the other diagnoses that have been provided during the appeal, the examiner was to opine whether or not these diagnosed conditions began in or were at least as likely as not (a probability of 50 percent or greater) related to service. Rationales were to be offered for all opinions expressed. In accord with the Board's remand directives, the Veteran was accorded a new VA medical examination in January 2011, the results of which were consistent with the Board's remand directives. In pertinent part, the examiner determined that the Veteran did not meet the diagnostic criteria for PTSD as per DSM-IV. Rather, the examiner found that the Veteran met the diagnostic criteria for malingering and polysubstance dependence in reported full, sustained remission. The examiner supported this opinion by reference to the specific diagnostic criteria for these diagnoses, the objective findings as to the Veteran's claimed symptomatology on examination, as well as the findings of other clinicians in the record. It was also indicated that the nature of malingering was such that it was not related to service. However, in the March 2012 remand, the Board noted that it was not clear whether the Veteran has any type of acquired psychiatric disorder that is causally related to his military service. Additionally, there had been a significant change in the law regarding PTSD claims during the pendency of this case, as discussed above. 75 Fed. Reg. 39843-52 (July 13, 2010). However, these revised provisions were not addressed in the most SSOC at that time. As such, this issue was remanded in March 2012 to correct this deficiency. The Board further noted in the March 2012 remand that the incidents documented in the Command Chronology, noted above, do appear to raise the matter of whether the Veteran has PTSD, or another acquired psychiatric disorder, based upon "fear of hostile military or terrorist activity." However, this matter did not appear to have been addressed by the January 2011 VA examination. Although the examiner determined the Veteran did not satisfy the diagnostic criteria of PTSD, without an opinion as to matter of "fear of hostile military or terrorist activity" as required by the revised regulatory provisions, the Board concluded in the March 2012 remand that all development required by law for an equitable disposition of the instant case had not been accomplished and remanded the case for clarification from the January 2011 VA examiner as to this issue. In March 2012, the examiner who conducted the January 2011 VA examination provided another VA medical opinion. The examiner reviewed the claims file and determined that the Veteran does not have a diagnosis of PTSD that conforms to the DSM-IV criteria. The examiner determined that the opinion rendered by the compensation and pension report dated January 21, 2011, by this examiner remains. The examiner stated that, after a claims file review and electronic medical records review, it is her professional medical opinion that the Veteran does not meet the diagnostic criteria for PTSD as per DSM-IV-TR (in other words, does not suffer from PTSD). The examiner went on to note that the Veteran's Axis I diagnoses of malingering and polysubstance dependence in reported full sustained remission are not related to "fear of hostile military or terrorist activity". The examiner indicated that the rationale provided on the same report dated January 21, 2011 remains. It was evident that, at the time of the examination, the Veteran was malingering, in other words, fabricating symptoms suggestive of mental disorder. The Veteran was not psychotic at the time of the examination. The Veteran had a strong history of alocohol and drug use resulting in legal problems. The Veteran's subjective symptoms of "seeing Charlie" is not typical presentation of PTSD or true psychosis. The examiner requested that it please be noted that at least 3 different examiners agree that the Veteran's presentation is not true PTSD. The Board notes that the claims file contains varying opinion as to whether the Veteran has a diagnosis of PTSD or any other psychiatric disability that is related to his active duty service. In this regard, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Upon review of the claims file and all relevant medical evidence of record, the Board finds the January 2011 and March 2012 VA opinions to be the most probative medical opinions of records on the matter. The examiner, who is a psychiatrist, reviewed the claims file, examined the Veteran, and offered a detailed rationale for her opinions. Moreover, these opinions were essentially supported by the September 2009 VA opinion. As discussed above, in the January 2011 VA examination report, the examiner determined that the Veteran did not meet the diagnostic criteria for PTSD as per DSM-IV. Rather, the examiner found that the Veteran met the diagnostic criteria for malingering and polysubstance dependence in reported full, sustained remission, and that the nature of malingering was such that it was not related to service. In the March 2012 VA examination report, this examiner again determined that the Veteran does not have a diagnosis of PTSD that conforms to the DSM-IV criteria. The examiner went on to note that the Veteran's Axis I diagnoses of malingering and polysubstance dependence in reported full sustained remission are not related to "fear of hostile military or terrorist activity". The examiner indicated that the rationale provided on the same report dated January 21, 2011 remains. It was evident that, at the time of the examination, the Veteran was malingering, in other words, fabricating symptoms suggestive of mental disorder. The Veteran was not psychotic at the time of the examination. The Veteran had a strong history of alocohol and drug use resulting in legal problems. The Veteran's subjective symptoms of "seeing Charlie" is not typical presentation of PTSD or true psychosis. The examiner requested that it please be noted that at least 3 different examiners agree that the Veteran's presentation is not true PTSD. With regard to the February 2008, October 2008, and September 2009 VA examinations, the Board notes that all of these examinations were conducted by the same examiner, who ultimately came to the same conclusion as the January 2011/March 2012 VA examiner regarding malingering and PTSD. At both of the 2008 VA examinations, the examiner indicated that the Veteran did not meet the criteria for a diagnosis of PTSD but did diagnose the Veteran with depressive disorder, NOS and cognitive disorder, NOS. However, this examiner ultimately altered his diagnosis at the September 2009 VA examination, at which he assigned an Axis I diagnosis of "Malingering. Rule Out (consider) Cognitive Disorder NOS. Cocaine Dependence, in reported full sustained remission. The examiner noted that the Veteran's dramatic presentation at this examination was in sharp contrast with his presentation in the compensation and pension examination following this examination. At the audiology examination, the Veteran did respond to some questions in a relevant and coherent manner. Therefore, the Veteran does have the ability to provide at least some relevant information and his attempt to present as incapable is most likely attributable to an effort to appear impaired so that that he can receive service connection for a psychological condition. The diagnosis of cognitive disorder was assigned in the October 2008 VA examination. However, the current diagnosis of cognitive disorder NOS has the qualifier "rule out" because some or all of the Veteran's observed cognitive impairment appears to be malingered. The Veteran has a history of cocaine dependence and this is in reported remission. The examiner concluded by noting that, because the Veteran apparently did not cooperate with the examination, the examiner would have to resort to mere speculation to opine if he meets the criteria for PTSD. Therefore, while the September 2009 VA examiner indicated that he could not entirely rule out a current diagnosis of cognitive disorder NOS, the Board finds that the September 2009 VA opinion essentially supports the March 2012 VA opinion that the Veteran was unresponsive of his own volition and, as such, his diagnosis was that of malingering. The Board notes that the Veteran has a responsibility to cooperate with VA in matters involving the development of his claim, noting that the Court has held that "[t]he duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, as the January 2011/March 2012 VA examiner clearly indicated that the Veteran does not meet the criteria for PTSD, that the Veteran's psychiatric diagnosis of malingering was not related to service, that the Veteran's Axis I diagnoses of malingering and polysubstance dependence in reported full sustained remission are not related to "fear of hostile military or terrorist activity", and that the Veteran has no other diagnoses of acquired psychiatric disabilities, the Board finds that the claim for service connection for an acquired psychiatric disorder, to include PTSD must be denied. Simply, the most probative medical opinions of record do not reflect that the Veteran has a current diagnosis of PTSD or an acquired psychiatric disability that is related to his active duty service, to include "fear of hostile military or terrorist activity." In this regard, it is noted that a VA psychiatrist indicated in a January 2010 medical record that the Veteran saw "Charlie" and that she thought this was a steroid induced psychosis. Over the course of his hospitalization she did not see his symptoms as true PTSD because once the psychotic symptoms resolved, he had no PTSD symptoms. She also noted that the Veteran became quite demanding over the course of the hospitalization and showed a strong sense of entitlement. The psychiatrist ultimately diagnosed psychosis NOS with chronic delusions regarding Vietnam opponents. However, the clinician did not link the psychosis to his active service. Additionally, with regard to the Veteran's polysubstance dependence in reported full sustained remission, the controlling law provides that service connection may be established for disability resulting from personal injury or disease incurred in or aggravated by service, but no compensation shall be paid if the disability was the result of the person's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). With respect to alcohol and drug abuse, section 8052 of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Public Law No. 101-508, § 8052, 104 Stat. 1388, 1388-351, prohibits, effective for claims filed after October 31, 1990, payment of compensation for a disability that is a result of a Veteran's own alcohol or drug abuse. See 38 U.S.C.A. § 1131 (2012). Moreover, the evidence indicates that polysubstance abuse has apparently been in remission during the pendency of this claim. Neither the Veteran nor his wife have reported active use or abuse during the pendency of this claim. Therefore, service connection for polysubstance dependence cannot be granted on a direct basis as a matter of law. In denying this claim, the Board has considered the other medical evidence of record. Specifically, the Veteran's treatment records contain diagnoses of PTSD, and of acquired psychiatric disorders other than PTSD, including severe psychosis, anxiety disorder, NOS, delirium NOS, and depression, NOS. While the Board has considered these diagnoses, the Board finds these opinions to be less probative than those offered by the January 2011/March 2012 VA examiner. As discussed, this examiner specifically reviewed the entire claim file twice and considered the Veteran's assertions in light of all other medical evidence of record. Therefore, the Board finds her opinion to be more probative based on her comprehensive review of all evidence of record, as opposed to diagnoses based primarily on conversations with the Veteran, particularly after it has been noted by 2 VA examiners that the Veteran is purposefully nonresponsive and malingering. The Board acknowledges the Veteran's contentions that he has PTSD or a psychiatric disability as a result of his active duty. Certainly, the Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran, as a lay person has not been shown to be competent to offer opinions on complex medical questions, such as whether he has a current psychiatric disability or PTSD related to his active duty service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). Thus, his lay assertions suggesting diagnosis and causation are far outweighed by the January 2011 and March 2012 opinions by the VA psychiatrist. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder, to include PTSD, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. There is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is denied. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs