Citation Nr: 1309067 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 07-13 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Chisholm Chisholm & Kilpatrick LTD WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from July 1977 to December 1980. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In May 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in May 2009. In November 2009, the Board remanded this case for further development. As a preliminary matter, the Board observes that the development directed by this remand was substantially completed. Although the Veteran did not undergo a VA examination as directed by this remand, the record to include an August 2010 Supplemental Statement of the Case (SSOC) reflects that such examinations were scheduled for April and June 2010, but the Veteran failed to appear. Thus, the Board finds there is no prejudice to the Veteran by proceeding with adjudication of this case, and that a new remand is not required under Stegall v. West, 11 Vet. App. 268 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (Remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In April 2011, the Board requested the opinion of a medical specialist from the Veterans Health Administration (VHA). The opinion was received in May 2011. In June 2011, the Board informed him that it had requested a specialist's opinion in conjunction with his appeal, provided him a copy of that opinion and indicated that he was entitled to submit additional evidence or argument within 60 days of the date of that letter. In August 2011, his representative submitted additional argument in support of the claim in response to the May 2011 VHA opinion. In September 2011, the Board issued a decision denying service connection for an acquired psychiatric disorder. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2012 Order, the Court, pursuant to a joint motion, vacated the Board's September 2011 decision and remanded the case for action consistent with the terms of the joint motion. In January 2013, the Veteran's attorney submitted additional evidence in support of his claim to include a private medical opinion from W. J. Anderson, Psy.D., Licensed Psychologist. Initial consideration of this evidence by the agency of original jurisdiction (AOJ) was waived pursuant to 38 C.F.R. § 20.1304 (2012). Therefore, the Board will proceed with adjudication of this case. FINDINGS OF FACT The evidence of record reflects it is at least as likely as not that the Veteran developed a psychotic disorder as a result of his active service. CONCLUSION OF LAW The criteria for a grant of service connection for psychotic disorder are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants service connection for an acquired psychiatric disorder. As this represents a complete grant of the benefit sought on appeal, no discussion of VA's duty to notify and assist is necessary. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In addition to the general rules of service connection noted above, service connection for posttraumatic stress disorder (PTSD) requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Further, 38 C.F.R. § 4.125(a) requires that diagnoses of mental disorders conform to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and that if a diagnosis is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis. The DSM-IV provides two requirements as to the sufficiency of a stressor: (1) A person must have been "exposed to a traumatic event" in which "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and (2) "the person's response [must have] involved intense fear, helplessness, or horror". DSM-IV at 427-28. These criteria are no longer based solely on usual experience and response but are individualized (geared to the specific individual's actual experience and response). Hence, under the DSM-IV, the mental illness of PTSD would be treated the same as a physical illness for purposes of VA disability compensation in terms of a predisposition toward development of that condition. Cohen v. Brown, 10 Vet. App. 128, 141 (1997). In Zarycki v. Brown, 6 Vet. App. 91 (1993), the Court held that the presence of a recognizable stressor is the essential prerequisite to support the diagnosis of PTSD. For all claims pending before VA on or after July 13, 2010, the provisions of 38 C.F.R. § 3.304(f) were amended by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (f)(3) 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, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means 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, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 75 Fed. Reg. 39,843 (July 13, 2010), with correcting amendments at 75 Fed. Reg. 41,092 (July 15, 2010). As the Veteran's claim was appealed to the Board before July 13, 2010, but had not been decided by the Board as of July 13, 2010, the amended regulations apply to the instant claim. The Board notes that, in claims for PTSD based on personal or sexual assault, VA has a heightened duty to notify the veteran. Gallegos v. Peake, 22 Vet. App. 329 (2008); 38 C.F.R. § 3.304(f)(5). Specifically, the special provisions set forth under the VA Adjudication Procedure Manual M21-1 (M21-1), Part III (Feb. 20, 1996) must be considered. 38 C.F.R. § 3.304(f)(5) (redesignated, as of July 13, 2010); 75 Fed. Reg. 39843 (July 13, 2010); Patton v. West, 12 Vet. App. 272 (1999) (Special M21 manual evidentiary procedures apply in PTSD personal assault cases). VA will not deny a PTSD claim that is based on in-service personal assault without first advising the Veteran that evidence from sources other than service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 38 C.F.R. § 3.304(f)(5). The United States Court of Appeals for the Federal Circuit (Federal Circuit) recently observed that 38 C.F.R. § 3.304(f)(5) specifically states that a medical opinion may be used to corroborate a personal-assault stressor, noting "medical opinion evidence may be submitted for use in determining whether the occurrence of a stressor is corroborated." See Menegassi v. Shinseki, 683 F.3d 1379, 1382 (Fed. Cir. 2011) (Observing that the United States Court of Appeals for Veterans Claims (Court) erred when it determined that a medical opinion based on a post-service examination of a Veteran cannot be used to establish the occurrence of a stressor); see also Patton, 12 Vet. App. at 280 (Rejecting the requirement that "something more than medical nexus evidence is required for 'credible supporting evidence' " in personal-assault cases). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that 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). 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). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. 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. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran essentially asserts that he had no psychiatric disability prior to service and has suffered from psychiatric disability since that time. As such, he maintains that service connection is warranted. The Board acknowledges that the Veteran is competent, as a lay person, to describe his visible symptomatology. However, psychiatric conditions involve complex medical issues, to include the specific type of diagnosis for such symptoms. In fact, as detailed below, various diagnoses have been attributed to the Veteran's purported symptoms. Thus, competent medical evidence is required to determine the specific diagnosis for the Veteran's purported symptomatology. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). Nevertheless, his account of his symptomatology can serve as the basis for a subsequent diagnosis and opinion by a competent medical care professional. The service treatment records reveal that upon examination at enlistment in June 1977 the Veteran reported that he had made a suicide attempt at age 13 because of family problems and that his problems were now resolved. He was subsequently hospitalized in November 1980 with a provisional diagnosis of adjustment reaction with suicidal ideation after he had made a verbal threat of suicide and a suicidal gesture by trying to drink a bottle of poison. His speech was spontaneous and coherent, there was no evidence of affective or thought disorder, and he denied substance abuse, paranoid delusions and suicidal and homicidal ideation. He indicated that he desired a hardship discharge so that he could be home to help his family. The Veteran was diagnosed with an adjustment disorder and it was noted that he did not appear to be a danger to himself or others. Subsequently, during his treatment in November 1980, the Veteran complained of being pushed around and of being tired and requested a hardship discharge. On mental status evaluation there was no evidence of psychosis or neurosis. Later during his treatment in November 1980 the Veteran was noted to have threatened to drink poison if he did not get out of the Navy. A history of several manipulative suicidal gestures in the past was also noted. The final diagnosis after hospital evaluation was passive dependent personality and manipulative effort to avoid military duty. In addition, he was noted to be fully responsible for all of his actions. The post-service medical records reveal that the Veteran was hospitalized in a VA hospital in July and August 1983 at which time a one-year history of depression and vegetative symptoms was reported. Also reported was a history of alcohol abuse and a three-year history of amphetamine abuse. The final diagnoses were alcohol abuse and amphetamine abuse. He was again hospitalized from August to November 1983 after initial admission to the substance abuse treatment unit. During this hospitalization he complained of vague hallucinations. However, psychological testing did not confirm any thinking disorder, and after treatment and evaluation, the final diagnoses were continuous alcohol dependence, continuous substance abuse with marijuana and amphetamines and schizotypal personality disorder. The hospital report reflected that he constantly asked for Thorazine and that no medications were given him at discharge. Follow-up records from November 1983 reflect the Veteran reported that he had developed hallucinations in service in 1979 and that these symptoms along with his paranoia led to feelings of anger, depression and sadness and consequently to many suicide attempts. He related that he had been given Thorazine and Atarax during his most recent hospitalization and denied current hallucinations. The mental status examination revealed the Veteran to be casually and appropriately dressed. He was noted to be on time. He was pleasant and cooperative. He was oriented times three. He answered questions respectfully and thoughtfully. He appeared relaxed and at east. The Veteran's associative processes were coherent without any loosening or distractibility. He was able to express his ideas in a logical, coherent manner and appeared goal-oriented. He showed appropriate affect, emotion, insight, and judgment. His memory showed no deficit. In December 1983 the Veteran reported that he started to have hallucinations again. He reported being somewhat depressed and had fleeting suicidal ideation. In April 1984 the Veteran was diagnosed with paranoid schizophrenia and in May 1984 he was diagnosed with anxiety. In September 1984 the Veteran complained of depression and was diagnosed with paranoid schizophrenia and depression. In another treatment note dated in September 1984 the Veteran was diagnosed with polysubstance abuse and depression. In June 1984 the Veteran was afforded a VA Compensation and Pension (C&P) examination. The Veteran reported difficulty sleeping, poor appetite, and being tense, nervous, and frequently depressed. He reported drinking to calm his nerves and vaguely admitted to using drugs. He stated that he could not get along with people and reported treatment for his alcohol and drug abuse. Examination revealed the Veteran to be suitably dressed. He gave relevant answers and was coherent but not cooperative and frequently evasive. He was tense and spoke rapidly. He was suspicious and vaguely admitted to hallucinatory experiences but it was unclear whether this occurred apart from alcohol and drug intake. He reported memory lapses and his emotional reaction was depression. Insight and judgment were marginal. After examination, the Veteran was diagnosed with history of alcohol abuse and personality disorder schizoid type. Subsequent VA inpatient and outpatient treatment records reflect diagnoses of schizophrenia (See September 1984, October 1984, June 1985, August 1985, August 2005 outpatient records) and depression and anxiety (See September 1984 and 1986 outpatient records) along with consistent diagnoses of alcohol and drug abuse. In October 1990 the Veteran was diagnosed with major depressive disorder with psychotic features and in December 1990 he reported visual hallucinations. A personality disorder has also been diagnosed on numerous occasions, and on hospitalization in November 1991 major depression with psychotic features was diagnosed along with cocaine and alcohol abuse. He was diagnosed as having adjustment disorder with mixed emotions, continuous alcohol and cocaine dependence and personality disorder with antisocial features on hospitalization in February 1992, and after hospitalization in April 1992 the diagnoses were continuous alcohol and cocaine dependence and antisocial personality disorder. In October 1991, September 2005, and July 2005 the Veteran was diagnosed with depression. In a private inpatient treatment note, dated in March 2005, the Veteran was diagnosed with major depression with psychotic feature, cocaine, alcohol, and marijuana dependence. In September 2005 the Veteran was diagnosed with cocaine abuse, in remission, and depression. Social Security Administration (SSA) records associated with the claims file reflect findings of depression, including records dated in October 2001, September 2005, and January 2006. At the May 2009 Board hearing the Veteran testified that he did not have any psychiatric conditions prior to service. At the hearing he identified several in-service incidents that he contends was the basis for his current psychiatric disorder. He reported an incident where he was assaulted by a Chief H., who purportedly hit him over the head with a shackle. He also indicated that he began to hear voices after this incident. Further, he reported another incident where he was assaulted by shore patrol at a Christmas party in barracks while stationed in Guantanamo Bay, Cuba; as well as an incident where a friend of his was killed by a marine while they were on R&R in Haiti. He also stated that he received a reduction in rank during service because of failure to return to Guantanamo for a court martial conducted as a result of the incident where his friend was killed. Moreover, he indicated that he continuously had problems of his same psychiatric condition that he had today since he left service in 1980. In short, the Veteran's testimony reflects that he developed a chronic psychiatric disability during service. In May 2009 Dr. K. Best diagnosed the Veteran with psychosis NOS and alcohol dependence in sustained recovery. No opinion rendered regarding the etiology. In May 2011 a VHA specialist opined that the Veteran's history and presentation in the past are consistent with a diagnosis of personality disorder. In opinion the physician noted that although the Veteran has been given diagnoses of major depressive disorder with psychotic features and schizophrenia, given the Veteran concurrent substance use and/or withdrawal and the documented pattern of his symptoms and his mental status examination, the supplied evidence does not support these diagnoses. The physician reported that although the Veteran has reported some anxiety and nervousness in the past, it did not appear to reach the level of a significant anxiety disorder and may have been secondary to another factor such as substance use/withdrawal, personality disorder, and psychosocial stressors. The VHA specialist stated that based upon the records it seems unlikely that the Veteran would have met the criteria for a substance abuse disorder prior to his entry to active duty. The records do not reveal any reported substance use until after November 1980. The physician noted that an opinion could not be rendered regarding whether the Veteran had a personality disorder prior to service because they are not usually diagnosed prior to the age of 18 with the exception of antisocial personality disorder and there is inadequate data present to render this opinion. The VHA specialist opined that the Veteran's substance abuse disorder was less likely than not related to his active service. The physician stated that the Veteran's personality disorder more likely than not had its onset in service. The physician relied upon the Veteran's November 1980 treatment for a suicidal gesture and the assessing clinician's belief that it was not suicidal but a manipulative effort to avoid military duty. The Veteran was noted in November 1980 to be fully responsible for his actions and to have no evidence of psychosis/neurosis. He was diagnosed at the time with passive dependent personality. Lastly, the VHA specialist opined that based upon a review of the file the Veteran did not have a primary psychotic illness that had its onset within one year of discharge from service. In a private medical statement received in January 2013, Dr. Wende J. Anderson included the results of a mental status examination conducted on the Veteran, as well as an accurate summary of the documented medical history of the Veteran similar to what is detailed above. Dr. Anderson diagnosed the Veteran with psychotic disorder not otherwise specified (NOS); major depressive disorder, recurrent; panic disorder with agoraphobia; and personality disorder NOS. Moreover, Dr. Anderson stated that overall, based on a review of the claims file, it is as likely as not that the Veteran experienced the onset of a psychotic disorder during his military service. Dr. Anderson also stated that based on the available documentation, the Veteran met criteria for a psychotic disorder since his military service. Dr. Anderson supported these opinions by stated rationale with reference to specific evidence in the record to include the service treatment records. In reviewing the aforementioned evidence, the Board observes that to the extent the Veteran's symptoms have been attributed to a personality disorder, VA regulations mandate that personality disorders are not diseases or injuries for VA purposes and therefore are not disabilities for which service connection can be granted. 38 C.F.R. § 3.303(c); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). The Board also wishes to note that to the extent the Veteran's symptoms have been attributed to substance abuse problems, the law has consistently precluded payment of compensation for a disability that is a result of a Veteran's own alcohol or drug abuse is prohibited by law. 38 U.S.C.A. § 105(a); 38 C.F.R. §§ 3.1(m), 3.301(d). The Board acknowledges that the Veteran has reported several purported in-service stressors as the basis for his current psychiatric disorder, to include assault. However, it does not appear that his purported stressors involve the type of "fear of hostile military or terrorist activity" as defined by 38 C.F.R. § 3.304(f)(3) (2012). Moreover, the record does not indicate that the Veteran's symptoms have been competently diagnosed as PTSD, nor that they are due to his purported stressors. Thus, it does not appear service connection is warranted for PTSD. Despite the foregoing, the record does reflect the Veteran has been diagnosed with other acquired psychiatric disorders to include psychotic disorder, schizophrenia, and depression. However, in September 2011 the Board denied the claim noting that the Veteran was diagnosed with a personality disorder during service and no other psychiatric disorder; and that while post-service treatment notes reveal consistent diagnosis and treatment for a variety of psychiatric disorders, there was no indication that any of these diagnosed psychiatric disabilities may be related to the Veteran's active service. Finally, the Board noted the findings of the May 2011 VHA opinion to include the conclusion that the diagnoses of depression and schizophrenia were not supported by the evidence of record and, rather, the Veteran's psychiatric disorder was best diagnosed as a personality disorder and a substance abuse disorder. In the joint motion that was the basis for the Court's April 2012 order the parties agreed that the Board denied entitlement to VA disability benefits for an acquired psychatiric disorder for lack of a current diagnosis, but failed to discuss the credibility and probative value of Dr. Best's May 2009 report which provided a diagnosis of psychosis. Because the Board did not discuss the relative probative value of Dr. Best's May 2009 report, it was agreed that it remained unclear as to whether the Board fulfilled its duty to weigh evidence prior to reaching its ultimate conclusion. The Board wishes to emphasize that it did note Dr. Best's May 2009 statement in the September 2011 decision, to include the diagnosis of psychosis. However, as noted at that time Dr. Best did not render an opinion regarding the etiology of this diagnosis. The Board also found that there was no indication that any of the psychiatric disabilities diagnosed after service may be related to the Veteran's active service. Although the Board did not specifically refer to Dr. Best's diagnosis of psychosis in making this finding, this was a general statement that referred to all such disabilities diagnosed post-service which is consistent with the Board's notation that no etiology opinion was provided when it did refer to Dr. Best's statement. Moreover, the Board found in the September 2011 decision that there was no indication the Veteran manifested any psychosis within one year of separation from service. As such, entitlement to service connection on a presumptive basis for a psychosis was not warranted. Further, the Board wishes to note that while it did find that service connection was not warranted for the Veteran's personality disorder, and noted the May 2011 VHA opinion that the diagnoses of an acquired psychiatric disorder for the Veteran's symptoms was not supported by the evidence, it did not explicitly deny the claim on the basis of lack of current diagnosis. The Board noted various diagnoses of acquired psychiatric disorders in the record, but found that the preponderance of the evidence showed that an acquired psychiatric disorder was not incurred in or aggravated by one or more reported in-service personal assault stressors or was otherwise related to any aspect of the Veteran's active service. The Board notes, however, that the evidence of record has changed since the time of the September 2011 decision with the addition of the January 2013 private medical statement from Dr. Anderson. As detailed above, Dr. Anderson found the Veteran's psychotic disorder developed while he was on active duty, and supported these opinions by stated rationale with reference to specific evidence in the record to include the service treatment records. Granted, this opinion is contrasted by the in-service diagnoses of personality disorder as well as the May 2011 VHA opinion which essentially found that the Veteran's symptoms were due to a personality disorder only. Nevertheless, Dr. Anderson's statement accurately noted the Veteran's in- and post-service symptomatology and medical history. Further, there does not appear to be any dispute as to Dr. Anderson's competency to render such a medical opinion. In summary, there is competent medical evidence that both supports and refutes a finding that the Veteran's documented in-service symptomatology was the first manifestation of his current acquired psychiatric disorder. The Board observes that these opinions, to include the May 2011 VHA opinion and the January 2013 statement from Dr. Anderson, were both promulgated based upon an accurate understanding of the Veteran's medical history and supported by stated rationale which included accurate references to this documented history. Although these medical care professionals reached opposite conclusions based upon this evidence, there is nothing in the record which leads the Board to question the competency or motivations of these individuals in rendering these opinions. Thus, the evidence appears to be in equipoise as to whether the Veteran's current acquired psychiatric disorder was incurred while on active duty. 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). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. 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. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In Alemany v. Brown, 9 Vet. App. 518 (1996), the Court noted that in light of the benefit of the doubt provisions of 38 U.S.C.A. § 5107(b), an accurate determination of etiology is not a condition precedent to granting service connection; nor is "definite etiology" or "obvious etiology." Further, in Gilbert, supra, the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." In Gilbert the Court specifically stated that entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine established by Congress, when the evidence is in relative equipoise, the law dictates that the appellant prevails. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the record reflects it is at least as likely as not that he developed an acquired psychiatric disorder as a result of his active service. Therefore, service connection for psychotic disorder is warranted. ORDER Service connection for psychotic disorder is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs