Citation Nr: 1310046 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 09-01 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUE Entitlement to service connection for a psychiatric disorder, to include post-traumatic stress disorder (PTSD) and paranoid schizophrenia. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from June 1968 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied reopening the Veteran's claim for a psychiatric disorder. The Veteran timely appealed that decision. The Board notes that the September 2006 rating decision denied a request to reopen a claim of service connection for PTSD, without reference to any other psychiatric disability, including schizophrenia. However, the Board has recharacterized the issue on appeal in order to comport with Clemons v. Shinseki, 23 Vet. App. 1 (2009), which held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. The appeal was previously before the Board in August 2011, at which time it was determined that new and material evidence had been received to reopen the claim of service connection for a psychiatric disability. The reopened appeal was then remanded for additional development and to provide the RO with a chance to consider the claim on a de novo basis. The requested development has been completed, and the appeal has been returned to the Board for further appellate consideration. The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. It does not contain any evidence not already in the claims folder or considered by the RO in the most recent supplemental statement of the case. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in May 2011. A transcript of that hearing is associated with the claims file. In January 2013, the Veteran submitted additional evidence in support of his claim. This evidence was received after the most recent supplemental statement of the case in December 2012, and he did not submit a waiver of initial adjudication of this material by the RO. However, a review of this material shows that it consists entirely of photocopies of statements from the Veteran and medical texts that have previously submitted by him and considered by the RO on several occasions. Therefore, the Board is not obligated to return the appeal to the RO for initial consideration, and may proceed with adjudication of the claim without fear of prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). FINDINGS OF FACT 1. The Veteran is presumed to have been sound upon entry into active service, and there is no clear and unmistakable evidence that a psychiatric disability existed prior to service. 2. The Veteran has never been diagnosed with PTSD. 3. Schizophrenia first manifested many years after discharge from service, and there is no continuity of symptomatology between active service and the initial manifestation of schizophrenia after active service. 4. The preponderance of competent evidence weighs against a finding that the Veteran's schizophrenia began in or is otherwise related to active service. CONCLUSION OF LAW A psychiatric disorder, to PTSD and paranoid schizophrenia, was not incurred in or aggravated by active service, nor may schizophrenia be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.384 (2012) REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 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. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In this case, the Veteran was provided with a letter in April 2006 that contained all of the notification required by 38 C.F.R. § 3.159, as defined by Dingess and Pelegrini. This letter was provided to the Veteran prior to the initial adjudication of his claim. The Board concludes that the duty to notify has been met. The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records have been obtained. Private medical records and VA treatment records have been obtained. The Veteran has offered testimony at a hearing before the undersigned Veterans Law Judge, and a transcript of this hearing is in the record. He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. Records have been obtained from the Social Security Administration (SSA). There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Service Connection The Veteran contends that he has developed PTSD as a result of active service during the Vietnam War. He argues that he first began to experience fear before he even joined the military when he was watching the war on television. Later, after he joined the Navy, the Veteran states that he was in fear of his life for the entire time that his ship was stationed off the shores of Vietnam or in Da Nang harbor. He argues that this fear has lead to the development of a psychiatric disorder, and that the proper diagnosis of this disorder is PTSD and not paranoid schizophrenia. 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 (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic disabilities noted in 38 C.F.R. § 3.309. Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997) With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In assessing medical opinions, the failure of the physician to provide a basis for his 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 file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999), and a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). The Board recognizes that a lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as tinnitus, hand pain, and shortness of breath, the Veteran is not competent to provide evidence as to more complex medical questions, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). If a psychosis such as schizophrenia becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of a psychosis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309, 3.384. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Initial Considerations The Veteran contends that his psychiatric disability is at least in part due to pre-service exposure to war videos on television. Other treatment records contain references to the difficulty in determining just when the prodromal phase of his disability began. A March 2006 VA treatment record states that the Veteran probably had paranoia throughout much of his life. A July 2011 VA treatment note says the Veteran reports the onset of his illness was from around age 16 or 17, which was consistent with schizophrenia. Therefore, the Board's August 2011 remand scheduled the Veteran for a VA psychiatric examination and, in part, directed the examiner to address the question as to whether or not the Veteran's psychiatric disability existed prior to service. The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). In order to rebut the presumption of soundness, the evidence, whatever it may be, must lead, clearly and unmistakably, to the conclusion that the injury or disease existed before the veteran entered the service. Harris v. West, 203 F. 3d 1347 (2000). In this case, the Veteran's June 1967 enlistment examination shows normal psychiatric findings. The Veteran denied a history of psychiatric symptoms on a Report of Medical History completed at that time. Personnel records completed in conjunction with his enlistment show his denial of ever being under the care of a psychiatrist or psychologist. Therefore, the Veteran is entitled to the presumption of soundness. The Board also finds that there is no clear and unmistakable evidence to show that the Veteran's psychiatric disability existed prior to service. There is no record whatsoever of any treatment of a psychiatric disability before service, and the Veteran denied such treatment at the time of his enlistment. He was afforded a VA psychiatric examination in September 2011, at which time the examiner reviewed the claims folder. This examiner opined that there was no clear and unmistakable evidence of a pre-existing psychiatric disability. There is no competent medical opinion to the contrary. As there is no clear and unmistakable evidence to rebut the presumption of soundness, and the Board will not need to further address whether or not a pre-existing disability was aggravated by service in its analysis of the Veteran's claim. PTSD In view of the Veteran's persistent belief that he currently has PTSD, the Board will discuss entitlement to service connection for this disability separately from his paranoid schizophrenia. The Veteran contends that he has developed PTSD as a result of stressors that occurred both before and during service. During service, he notes that he served aboard a Navy destroyer that was stationed off shore of Vietnam. The Veteran states that he was in fear of his life for this entire period while the ship was harbored in Da Nang. He strongly believes that the proper diagnosis of his disability is PTSD. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, 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. 38 C.F.R. § 3.304(f). Prior to July 13, 2010, VA generally required that, where a determination is made that the Veteran did not "engage in combat with the enemy," or the claimed stressor is not related 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 contain service records or other 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). The regulation was amended, effective July 13, 2010, to eliminate the requirement for corroborating evidence of the claimed in-service stressor if it is related to the Veteran's "fear of hostile military or terrorist activity." The newly amended regulation 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 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 posttraumatic stress disorder 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. 38 C.F.R. § 3.303(f)(3)). 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. Id. In this case, the Veteran has consistently maintained that he was in fear of losing his life at the hands of the enemy the entire time that he was stationed in Vietnam. His personnel records confirm that the ship to which he was assigned fired in support of infantry, and was otherwise stationed in Vietnamese waters. Therefore, the Board finds that the Veteran's reports of having experienced fear of hostile military activity are credible. However, the Board must also find that the evidence does not support entitlement to service connection for PTSD. The Veteran does not currently have, and in fact has never had, a diagnosis of PTSD rendered by a competent medical professional. The earliest evidence of record is a report of a May 1987 private examination. The Veteran stated that he had functioned well until 1980. He said there had been no need for psychiatric intervention until he was separated from his wife in 1980. He was said to have served in the Army during the Vietnam War. At the conclusion of the mental status examination, the diagnoses were chronic paranoid schizophrenia, and alcohol and substance abuse. A September 1987 SSA report on the Veteran's disability due to schizophrenia did not refer to active service or PTSD. A June 1993 private examination notes that the Veteran had been initially evaluated in 1987, at which time he was determined to have a psychotic disorder. A mental status evaluation resulted in diagnoses of chronic paranoid schizophrenia, and schizoaffective disorder. At a December 1994 private examination, the Veteran's military service was noted, although there were inaccuracies such as citing the incorrect branch of service. After completion of the interview and mental status examination, the diagnoses remained chronic paranoid schizophrenia, and schizoaffective disorder. The examiner added that "it was likely that he originally suffered from symptoms typical to PTSD but this condition was later super-imposed by much more severe symptoms and signs typical for severe schizophrenic disorder." A May 1998 private examiner again diagnosed the Veteran as having chronic paranoid schizophrenia. An August 2001 private examiner notes that the Veteran wanted to talk about PTSD, and his experiences in Vietnam were discussed at length. The examiner noted that the Veteran had experienced fear of death while serving in Vietnam, and he had displayed some avoidant responses. However, he did not fully meet the diagnostic criteria for PTSD. Instead, the diagnosis was paranoid type schizophrenia. The Veteran was afforded a VA PTSD examination in April 2004. A review of his record noted the prior diagnoses of schizophrenia, although it was also noted that the Veteran was likely to have been exposed to stressful incidents in service while serving on a destroyer off the coast of Vietnam. The Veteran denied ever receiving treatment for PTSD and he denied ever receiving treatment for any psychiatric disorder from VA. After an extensive review and discussion of the Veteran's history and symptoms, the impression was that the Veteran did not suffer from PTSD. The examiner cited to four criterions for PTSD, and found that the Veteran did not meet any of these. The examiner stated that "On the whole the veteran appears to have concluded erroneously that since he was in the military and people in the military do sometimes experience post-traumatic stress disorder, that he therefore has acquired post-traumatic stress disorder. This sort of concrete thought is not uncommon with people who suffer from a severe chronic mental illness such as schizophrenia." The diagnosis was paranoid type schizophrenia. Private treatment records from 2004 continue to diagnose the Veteran with chronic paranoid schizophrenia. VA treatment records dating from 2006 consistently identify the Veteran's mental disability as schizophrenia, and also consistently reflect that he does not have PTSD. A November 2008 VA treatment record from one of the several VA psychiatrists who have provided with Veteran with ongoing care states that the Veteran's history of persistence "in obtaining a SC for PTSD (which he clearly does not have) are representative of his disorganized thought process due to his chronic psychotic illness." The Veteran was afforded a second VA PTSD examination in September 2011. The claims folder and medical record were reviewed by the examiner, and the Veteran was interviewed. The examiner also notes the definition of a stressor as found in the recently amended version of 38 C.F.R. § 3.303(f)(3). The examination report outlined six criterions for a diagnosis of PTSD and found that the Veteran met only two of these criterions. The diagnosis was paranoid type schizophrenia. In her remarks, the examiner stated that the Veteran had heard about PTSD and became convinced that this was his proper diagnosis. Although he had been consistently told that his symptoms did not meet the criteria for PTSD and that he had paranoid schizophrenia, he was adamant that this was not correct and is certain that he will one day be awarded service connection. The examiner noted that while the Veteran experienced a stressor in that he feared for his life while serving off the shore of Vietnam, it was further noted that his response to this stressor was not consistent with PTSD. The current diagnosis was paranoid type schizophrenia. In light of the above, the Board finds that entitlement to service connection for PTSD is not warranted. The overwhelming preponderance of the evidence shows that the Veteran does not currently have and has never had a diagnosis of PTSD. A claimant must have the disability at time of application for VA benefits and not merely have findings in service potentially indicative of the claimed disability. See Degmetich v. Brown, 104 F.3d 1328, 1331-33 (Fed. Cir. 1997). The Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that Secretary's and Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Caluza v. Brown, 7 Vet. App. 498, 505 (1995); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). Again, the Veteran has never had a diagnosis of PTSD. The only evidence in his favor is the statement from the December 1994 examiner that it was likely he originally suffered from symptoms typical to PTSD before schizophrenia was superimposed, but the Board notes that, even if true, having symptoms typical to PTSD is not tantamount to diagnosis of PTSD. Moreover, this is not supported by the prior psychiatric records that date back to 1987, in which every record diagnosed schizophrenia and was negative for PTSD in spite of noting military service. Indeed, even the December 1994 report noting PTSD symptoms diagnosed not PTSD but rather paranoid schizophrenia. There is not a single diagnosis of PTSD contained in the extensive records dated subsequent to December 1994, and two VA PTSD examinations have found that the Veteran does not have this disability. The Board recognizes the Veteran's strong and sincere belief that he has PTSD, but this is not a disability for which a layman is competent to render a diagnosis. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board recognizes that while the Veteran undoubtedly experienced fear and stress during active service, this fear and stress in itself was not PTSD. In fact, the Veteran's examiners have indicated that his belief that he has PTSD is a symptom of his schizophrenia. As the Veteran does not have and has never had a competent current diagnosis of PTSD, entitlement to service connection for this disability is not established. Paranoid Schizophrenia The Board will now discuss whether or not service connection is appropriate for the Veteran's diagnosis of paranoid schizophrenia. The Veteran currently has a well established diagnosis of schizophrenia, and the requirement for a diagnosis of a current disability has been met. Therefore, the Board will examine whether he first developed schizophrenia during service and whether there is a relationship between the Veteran's current schizophrenia and any events during active service. The service treatment records are entirely negative for complaints or treatment pertaining to a psychiatric disability. The March 1970 discharge examination reflects normal psychiatric findings. The personnel records are negative for any behavior such as disciplinary actions or other misbehavior that might be associated with a psychiatric disability. As previously noted, the initial evidence of record showing psychiatric problems is a report of a May 1987 private examination. At that time, the Veteran stated that he had functioned well until 1980. There had been no need for psychiatric intervention until he was separated from his wife in 1980. The Veteran was said to have served in the Army during the Vietnam War. At the conclusion of the mental status examination, the diagnoses were chronic paranoid schizophrenia, and alcohol and substance abuse. The examiner did not relate this disability to service. A September 1987 SSA report found that Veteran was unable to work due to his paranoid type schizophrenia. A June 1993 private examination notes that the Veteran had been initially evaluated in 1987, at which time he was determined to have a psychotic disorder. A mental status evaluation resulted in diagnoses of chronic paranoid schizophrenia, and schizoaffective disorder. At a December 1994 private examination, the examiner interviewed the Veteran and his mother, and found that the Veteran's first psychotic break had occurred in 1978. They indicated that this was due to escalating stress in his relationships with his wife and father-in-law. The examiner noted that the Veteran had occasional contact with a VA hospital but there was no written documentation of treatment between 1970 and 1987. Following the mental status examination, the diagnosis was paranoid type schizophrenia. The summary noted that very little was known about the course of the Veteran's illness in its early stages because there was a lack of medical and psychiatric documentation until 1987 and very little was known about the prodromal stage of his psychiatric disorder. He added that it was likely the Veteran originally had symptoms similar to PTSD but that this was later super-imposed by much more severe symptoms and signs for severe schizophrenic disorder. A May 1998 private examiner diagnosed the Veteran with chronic paranoid schizophrenia. The history indicated an initial psychotic break around 1969 "after the service" when he apparently reported visual hallucinations and ideas of reference from the television. He continued to work as a circulation supervisor from 1966 to 1978, during which time the symptoms were quiescent. However, he began to experience ideas of reference in 1979 with increasing symptoms by 1980. The examiner did not provide an opinion as to the etiology of the Veteran's disability. An August 2001 private treatment record shows continued treatment for chronic paranoid schizophrenia, which the Veteran continued to believe was PTSD. A handwritten note reflects that the "stress of war may have been latent trigger for later psychotic processes or may have been a dynamic process by which it can regard any outside agency as responsible for advent of symptoms." In a January 2004 private treatment record, the Veteran described his first encounter with mental illness as having occurred in the reserves in 1970, when he was homeless and had thoughts of suicidal ideation. His symptoms worsened and he sought treatment in 1987. At the VA PTSD examination in April 2004, a review of his record noted the prior diagnoses of schizophrenia. After an extensive review and discussion of the Veteran's history and symptoms in which the Veteran was noted to be a poor historian, the impression was that the Veteran did not suffer from PTSD. The diagnosis was paranoid type schizophrenia. An opinion as to the etiology of schizophrenia was not offered. A November 2008 VA treatment record states that in previous discussions with the Veteran he had been able to describe his symptoms of schizophrenia as being present while he was in service, though his current level of symptoms rendered him an inaccurate historian. The examiner stated that "It is possible that his sx began while in the service and are certainly chronic and disabling in nature." A July 2011 VA treatment note from A-L. V., M.D., says the Veteran reports the onset of his illness was from around age 16 or 17, which was consistent with schizophrenia. It was not clear if the start of illness had been during service as described by the Veteran. Additional information was needed from family members to describe the course of his illness as his current illness interferes with the recounting of his symptoms in a meaningful way. A September 2011 VA treatment report written by Dr. A.V. contained in the electronic record notes that traditionally it had been very hard to obtain an accurate history from the Veteran because he was very focused on details and had delusional interpretations of events. The Veteran's fear during service was noted. He then reported not having any psychiatric problems from 1970 to 1978, at which time he began to experience delusions. More recent delusions involved Saddam Hussein and the current wars. It was not clear to the examiner whether the threat of war and the Veteran's military experience was the trigger or simply the stage in which the Veteran's already evolving mental illness played itself out. She expressed a belief that, more likely than not, it played a strong role in the development of schizophrenia and in the intensity of his illness course. She noted that examiners usually rely on an individual's history to determine the intensity and origination of psychiatric symptoms. In this case the Veteran was stating "as clearly as he can" given his severe mental illness that his psychiatric illness started with his time in service. The September 2011 VA examiner reviewed the Veteran's claims folder and medical records. The current diagnosis was paranoid type schizophrenia. The Veteran noted that he had returned to his previous job after his discharge from service in 1970 and that he did well during this period. However, the Veteran indicated that he began to have paranoid symptoms in 1978 when he began to believe he was being harassed by his employer. He was jobless and homeless by 1980. The examiner reported that some previous examiners had questioned whether or not the intense fear experienced by the Veteran in service may have been an early manifestation of his psychiatric illnesses. The September 2011 opinion from Dr. A.V. finding that the Veteran's exposure to the threat of war was a likely trigger for his illness, or at the very least contributed significantly to the development of the illness was also recognized. While the September 2011 examiner acknowledged that this was plausible, a review of the available information did not provide sufficient evidence to indicate at least a 50 percent probability that his illness began in service or was clearly related to military service. The only other evidence that might shed some light on this question would be the statement of someone who had known him since childhood and could testify as to the development of his illness. The Board finds that entitlement to service connection for schizophrenia is not warranted. The preponderance of the evidence is against a finding of a relationship between the Veteran's current disability and active service. The service treatment records are negative for any evidence of schizophrenia, and there is no evidence of treatment for schizophrenia during the first year after discharge from service. Therefore, service connection for schizophrenia may not be presumed. 38 C.F.R. §§ 3.307, 3.309, 3.384. Continuity of symptomatology must be considered for the chronic diseases listed in 38 C.F.R. § 3.309, including psychoses, which include schizophrenia. See 38 C.F.R. § 3.384. Although there is some conflict in the record as to when the Veteran's schizophrenia first manifested, the Board finds the evidence demonstrates that it did not manifest earlier than 1978. The Veteran has frequently provided histories to his many examiners that he did not experience symptoms during this period, and he has made similar assertions in his written statements and his hearing testimony. At this juncture, the Board acknowledges that the Veteran has been described as a poor historian by his doctors on many occasions. However, the July 2011 record from Dr. A.V. and the September 2011 VA examiner noted that the best means of obtaining an accurate history would be to interview someone who had known the Veteran since childhood and would be aware of the course of his illness. The Board notes that this was already accomplished in the December 1994 private examination when the Veteran's mother was interviewed and indicated that the Veteran's first psychotic break occurred in 1978. As there is no evidence of ongoing symptoms between the Veteran's 1970 discharge from service and the initial psychotic break in 1978, continuity of symptomatology is not established. Finally, the Board finds that the preponderance of competent medical opinion weighs against a finding of a nexus between the Veteran's schizophrenia and active service. The record shows that the Veteran has been examined on many occasions between 1987 and the present, and while many of both the private and VA examiners discussed the Veteran's active service as well as his beliefs as to having PTSD, none of them found it was as likely as not that his schizophrenia was incurred or aggravated due to service. A May 1998 private examiner states that the Veteran experienced his first psychotic break in 1969, but this is clearly inaccurate as this same examiner indicated that this was after service. The Veteran was not discharged until 1970, and as already noted his service treatment records are negative for evidence of a psychotic break. This examiner also inaccurately indicated that the Veteran had worked for a certain business from 1966 to 1978, when in fact he was in active service from 1968 to 1970. The August 2001 examiner acknowledged that the stress of war may have been a latent trigger for the Veteran, but it was also noted that the nature of his disability was such that other outside agencies could have also been triggers. A November 2008 treatment note also states that based on the history provided by the Veteran it was possible the schizophrenia began during service. These statements are speculative, and statements from doctors which are inconclusive as to the origin of a disease cannot fulfill the nexus requirement. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In Obert v. Brown, the Court held that a medical opinion expressed in terms of "may," also implies "may or may not" and is too speculative to establish a plausible claim. Bostain v. West, 11 Vet. App. 11 Vet. App. 124 (1998); Obert v. Brown, 5 Vet. App. 30 (1993). Finally, the Board recognizes the September 2011 statement from Dr. A.V. indicating that it is more likely than not that the Veteran's military experiences played a strong role in the development of schizophrenia and the intensity of his illness course. However, this statement must be viewed in the context of the July 2011 note from Dr. A.V. which noted that additional information was needed from family members to describe the course of the Veteran's illness, as it had interfered with the Veteran's ability to recount his symptoms. It must also be noted that Dr. A.V. qualified her opinion by stating that examiners usually rely on an individual's history to determine the intensity and origination of psychiatric symptoms, and that the Veteran was stating that his began in service. There is no indication that Dr. A.V. reviewed the December 1994 examination report with the history that was provided in part by the Veteran's mother saying the Veteran's first psychotic break was in 1978, or that she reviewed any of the Veteran's other private medical records that repeatedly state his schizophrenia began between 1978 and 1980. In contrast, the September 2011 VA examiner had access to the Veteran's entire claims folder, to include these earlier private medical records. This examiner noted and discussed the statement from Dr. A.V., but found that there was insufficient evidence to indicate at least a 50 percent probability that the Veteran's illness began in service or was clearly related to service. As the September 2011 examiner based her opinion on a medical history that was more accurate and complete than that available to Dr. A.V. in September 2011, the Board finds that it is the more probative of the two. That being the case, the preponderance of the evidence is against a finding that there is a nexus based on competent medical opinion between the Veteran's schizophrenia and active service. It further follows that entitlement to service connection for a psychiatric disability to include schizophrenia is not warranted. ORDER Entitlement to service connection for a psychiatric disorder, to include post-traumatic stress disorder and paranoid schizophrenia, is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs