Citation Nr: 1310260 Decision Date: 03/26/13 Archive Date: 04/02/13 DOCKET NO. 02-12 254 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected disabilities. 2. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder and/or to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from April 1967 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. On July 22, 2003, the Veteran testified via videoconferencing at a hearing before the undersigned Veteran's Law Judge. A transcript of that hearing is of record. The Board notes that the procedural history of this case is a lengthy one, involving multiple actions by the Board whereby the instant matters were remanded for further development. As will be discussed in further detail below, the Board finds that all required development has been completed in accordance with the terms of its prior remand. Accordingly, the Board may proceed with a decision. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that with regard to the Veteran's claim of service connection for hypertension, that claim was "reopened" by the Board in April 2009 and the underlying claim was remanded for further development and readjudication. In August 2010, the RO deferred a decision on that matter, pending a VA examination to determine the likelihood that the Veteran's hypertension had its onset in service. In August 2011, the RO issued another deferred rating decision, wherein it was noted that the Veteran was service connected for, among other things, diabetes mellitus and diabetic nephropathy. In accordance with the VA Adjudication Procedure Manual, M21-1 MR, Part III, Subpart iv, Chapter 4, Section F, para. 22.cc (Dec. 29, 2007), the RO therefore requested a medical opinion to determine the likelihood that the Veteran's hypertension was secondary to his service-connected diabetes mellitus. In June 2011, the Appeals Management Center (AMC) issued a supplemental statement of the case (SSOC) wherein it denied service connection for hypertension, to include as secondary to diabetes mellitus. In a July 2011 written brief presentation, the Veteran's representative raised the issue of entitlement to service connection for hypertension, as secondary to an acquired psychiatric disorder. In September 2011, the Board remanded the issue of entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder for further development. By way of a June 2012 SSOC, the AMC denied service connection for hypertension, noting that the evidence failed to show that the Veteran's hypertension was related to his military service or to a service-connected disability. The matter was again remanded in September 2012, as it was inextricably intertwined with the Veteran claim of service connection for an acquired psychiatric disorder. In light of this history and in accordance with the holding in Clemons v. Shinseki, wherein the United Stated Court of Appeals for Veterans Claims (Court) held that when determining the scope of a claim, the Board must consider "the claimant's description of the claim; the symptoms the claimant describes, and the information the claimant submits or that the Secretary obtains in support of that claim," 23 Vet. App. 1, 5 (2009), the Board finds that although the secondary service connection issue previously before the Board was limited to whether the Veteran's hypertension was secondary to an acquired psychiatric disability, the claim is more appropriately characterized as entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder and/or to service-connected diabetes mellitus, as reflected on the title page of this decision. FINDINGS OF FACT 1. At no time during the current appeal has the Veteran been found to have PTSD related to an alleged in-service stressor in accordance with the DSM-IV criteria, as required by 38 C.F.R. § 4.125. 2. The Veteran's currently diagnosed dysthymic disorder was first identified many years after service, is not shown to be related to his military service, and is not shown to be proximately due to, the result of, or made worse by a service-connected disability. 3. The Veteran's currently diagnosed hypertension was first identified many years after service, is not shown to be related to his military service, and is not shown to be proximately due to, the result of, or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. A psychiatric disorder, to include PTSD and/or dysthymic disorder, was not incurred in or aggravated by active service, nor is it caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012); 38 C.F.R. § 3.310 (2006). 2. Hypertension was not incurred in or aggravated by military service, may not be presumed to have been incurred in service, and is not secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012); 38 C.F.R. § 3.310 (20065). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008 and, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. 38 C.F.R. § 3.159(b)(1).) The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The instant matters stem from the Veteran's 2001 petition to reopen his previously denied claims of service connection for an acquired psychiatric disorder and hypertension, which claims were "reopened" by the Board in October 2006 and April 2009, respectively, and the underlying matters were thereafter remanded for further development and adjudication on the merits. In November 2006, the Veteran was sent a letter wherein he was notified of the evidence required to substantiate his underlying claims of service connection for an acquired psychiatric disorder, to include PTSD, and hypertension. The letter advised the Veteran of the information already in VA's possession and the evidence that VA would obtain on his behalf, as well as of the evidence that he was responsible for providing to VA, to include any records not in the possession of a Federal agency. It further advised the Veteran of the specific requirements for substantiating a PTSD claim, to include the need to submit specific details regarding the stressful incident(s) in service that led to his PTSD. The letter also included the notice elements required by Dingess, supra, pertaining to the assignment of a disability rating and effective date. The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the October 2006 notice letter complies with the requirements of 38 U.S.C.A. § 5103(a), and afforded the Veteran a meaningful opportunity to participate in the development of his claims of service connection on a direct basis. Notably, however, the Veteran was not provided with notice of how to substantiate his claims on a secondary basis. In this regard, the Board notes that it is the claimant who has the burden of demonstrating that a notice error occurred and that the notice error was prejudicial to the claim. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009). In the instant case, neither the Veteran nor his representative has raised an issue with regard to the adequacy of notice provided in this case. Further, it was the Veteran's representative who raised the issue of secondary service connection for an acquired psychiatric disorder and for hypertension, secondary to an acquired psychiatric disorder, during the pendency of the Veteran's claim and the acquired psychiatric disorder matter has twice been remanded by the Board for further development specific to the issue of secondary service connection. Moreover, the AOJ sought multiple medical opinions with regard to the issue of entitlement to service connection for hypertension, secondary to service-connected diabetes mellitus and/or an acquired psychiatric disorder. Given the facts of this case, the Board finds that although the Veteran was not specifically informed of how to substantiate his claims of service connection on a secondary basis, the Veteran did have a meaningful opportunity to participate in the development of his claims. Accordingly, the Board finds that the Veteran has not been prejudiced by notice error in this case. See Overton v. Nicholson, 20 Vet. App. 427, 235 (2006) (notice errors that render a claimant without a "meaningful opportunity to participate effectively in the processing of his or her claim" are prejudicial). Thus, the Board is satisfied that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were met. Further, the Board finds that VA has fulfilled its obligation to assist the Veteran. All available evidence pertaining to his claims has been obtained. The evidence includes his STRs, service personnel records, post-service VA treatment records, VA examination reports, and lay statements in support of his claims, to include his July 2003 hearing testimony. The Veteran has not identified any outstanding potentially obtainable records, and the Board is aware of none. In this regard, the Board notes that in compliance with the terms of its previous remands, attempts were made to obtain records from the Social Security Administration (SSA). In June 2009, however, the SSA responded stating that any medical records pertaining to the Veteran had been destroyed and thus further attempts to obtain such evidence would be futile. The Veteran was informed of the SSA's response via a July 2009 letter. The Board also notes that as part of an April 2009 remand, the AOJ was directed to take further action to verify the Veteran's alleged in-service stressors. In August 2009, the Veteran was sent a letter informing him that additional information was needed with regard to his alleged in-service stressors, particularly the reported stressor of a comrade's injury from a landmine in May 1968. He was requested to complete the enclosed PTSD questionnaire within 30 days. No response was received from the Veteran and in November 2009, it was determined that there was insufficient information to submit to the U.S. Army and Joint Services Records Research Center (JSRRC) a request for verification of the Veteran's alleged in-service stressors. Notably, a response to a previous request for morning reports to attempt to corroborate the Veteran's allegations regarding the comrade's mine field accident and a friendly fire incident revealed that Air Force morning reports ended in June 1966. Upon review of the action undertaken by the AOJ, the Board finds that the terms of its previous remands have been complied with to the extent possible and that no further assistance is warranted to attempt to corroborate the Veteran's alleged in-service stressors. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that the duty to assist is not a one-way street). This is especially so in a case such as this where, as will discussed in further detail below, even conceding the occurrence of the alleged in-service stressors, as described by the Veteran, VA clinicians have determined that those stressors are insufficient to support a diagnosis of PTSD in accordance with the DSM-IV criteria. Lastly, the Board notes that during his 2003 hearing, the Veteran indicated treatment at a VA medical facility within the year after discharge from service. Although it does not appear as though any specific request was made for records from the facility for the time period alleged, as will be discussed in further detail below, the Veteran's assertions in this regard are not credible. Thus, the Board does not find any reason to remand the matter to attempt to obtain records that do not appear to in fact exist. Further, as outlined above, the Veteran has been afforded multiple VA examinations and several medical opinions have been obtained in connection with his claims. Specifically, with regard to the Veteran's claim of service connection for an acquired psychiatric disorder, the VA examiners reviewed the claims folder and examined the Veteran, to include administering psychiatric testing. The examiners recorded the Veteran's subjective complaints related to psychiatric disability, considered his reported in-service stressors, and provided opinions regarding whether the Veteran indeed suffers from PTSD and whether his diagnosed dysthymic disorder is related to service. Further, in compliance with the Board's prior remands, the claims folder was reviewed by two different VA psychologists to determine the likelihood that the Veteran's dysthymic disorder was secondary to a service-connected disability. Concerning the Veteran's claim of service connection for hypertension, opinions have been obtained regarding the Veteran's multiple theories of service connection, which opinions are based on a review of the claims folder and consideration of accepted medical principles. Overall, the Board finds that the examinations and opinions obtained in this case are adequate, as they were predicated on a reading of the STRs and medical records in the Veteran's claims file, and based on consideration of all of the pertinent evidence of record, and are supported by adequate rationales. The Board thus concludes the Veteran was provided with adequate examinations and that the terms of the Board's prior remand were satisfied. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall, supra. II. Service Connection - PTSD A. Background A review of the Veteran's STRs shows that in June 1969, the Veteran was seen for complaints of anxiety stemming from unit problems. He was given a prescription for Valium and referred to mental hygiene. The remaining STRs are negative for psychiatric complaints, treatment, or diagnoses. The Veteran's February 1971 separation examination report indicates that he was clinically evaluated as being psychiatrically normal. It was noted that the Veteran had denied all significant medical history, save for stomach troubles and associated sleep problems. On the accompanying report of medical history, the Veteran denied nervous trouble of any sort, depression, and excessive worry. Post service medical records show that the Veteran was hospitalized in June 1974. Mental status examination revealed only a report of auditory hallucinations when on drugs. A July 1990 treatment record records a diagnosis of dysthymic disorder and states rule out PTSD. It appears that the Veteran had a period of inpatient psychiatric treatment in April 1991, but was not subsequently followed in mental health. In January 1994, he presented with complaints of depression. It was noted that he had been advised by family to seek treatment on account of his extensive anger towards the person who killed his daughter. The clinician recorded Axis I diagnoses of adjustment disorder with depressed mood, rule out organic affective disorder, and grief reaction. The Veteran's psychosocial stressor was noted to the death of his daughter. In September 1995, the Veteran presented with complaints of flashbacks and depressive symptoms, and was admitted for psychiatric treatment. His stressor was noted to be the deaths of his wife and daughter. He reported hearing voices since returning from Vietnam and stated that he used alcohol and drugs to anesthetize himself. The Veteran indicated that he had been living on the streets because he could not stand to live in his own home. The hospitalization report records Axis I admission and discharge diagnoses of PTSD, major depression, alcohol dependence and cannabis abuse. During a February 1996 mental status examination, the Veteran reported sometimes hearing voices related to Vietnam and indicated paranoid feelings at times and difficulty with crowds and people being behind him. The Veteran was diagnosed as having PTSD by history. Another VA clinician recorded an Axis I diagnostic impression of rule out dysthymia. In June 1996, the Veteran was afforded a VA PTSD examination. When asked about any in-service stressors, the Veteran reported being on guard duty while U.S. and Vietnamese exchanged fire, essentially over his head, for a 15 minute period. He did not participate in the exchange nor was he wounded as a result of it. He also reported being shot at repeatedly by a sniper who was toying with him and recalling that an acquaintance lost a foot in a mine field accident. The Veteran indicated difficulty sleeping since returning from Vietnam and occasional thoughts of Vietnam, triggered by such things as rainy weather and loud noises. The examiner noted that the Veteran spoke about Vietnam without hesitation but that it took him some time to provide any details regarding his in-service stressors. The examiner stated that the diagnosis of PTSD was questionable, as the Veteran did not exhibit all of the required symptomatology. The examiner also noted evidence of depression associated with the Veteran's loss of his wife and daughter. The examiner provided the following Axis I diagnoses: dysthymic disorder, chronic, moderate in intensity; rule out major depressive disorder, alcohol dependence, currently in full remission; polysubstance abuse and dependence, currently in reported remission and marijuana abuse and dependence. The examiner then stated his opinion that the Veteran's current psychiatric situation appeared to have more to do with the loss of his wife and daughter, as well as with the loss of his job, physical integrity, and concern for his health and welfare, and the "case for PTSD is extremely thin." In January 2000, the Veteran presented with complaints of increasingly severe PTSD symptoms. His stressors were noted to be his anniversary date, the holidays, and a discarded home. He reported strained relations with his girlfriend's son. Diagnoses of PTSD, by history, rule out major depressive disorder, and alcohol abuse were recorded and it was recommended that the Veteran undergo group, individual and milieu therapies. In July 2002, the Veteran testified at a Board hearing, during which time he relayed having been exposed to friendly fire while on guard patrol. He also reported that one of his comrades was jogging when he ran across a mine field and had his foot blown off. He further indicated being ambushed and having to hold Hill 151 because of enemy activity in front of the base. The Veteran underwent another VA PTSD examination in June 2008, during which several psychometric test and questionnaires were administered. Regarding his alleged in-service stressors, the Veteran reported the "friendly fire" incident and witnessing a sergeant's leg being blown off when he accidently jogged through a mine field. The Veteran did not cite any post-military stressors and denied any current psychiatric treatment. Psychometric testing was indicative of severe and catastrophic depression. The examiner noted, however, that the majority of the endorsed symptoms were in the most extreme range and reflected a wide array of diagnostic categories. Regarding the Veteran's PTSD score, the examiner stated that it raised the possibility of malingering. In total, the examiner found that the Veteran's score reflected gross over-reporting of symptoms, which were inconsistent with his reported military history and experiences and level of functioning across time. The examiner determined that the Veteran did not present with a valid criterion A stressor, or with the full constellation of symptoms for a diagnosis of PTSD. The examiner further noted that the description of the Veteran's reported stressors was inconsistent with prior reports, which, along with the gross over reporting of symptoms on psychometric testing, called into question the veracity of his report. The examiner rendered a diagnosed of dysthymia, unrelated to military service, and indicated that the Veteran's mood disturbance was very likely exacerbated by his chronic substance abuse. The Veteran was afforded another VA examination in September 2010, which also included psychiatric testing. The examiner reviewed the claims folder, noting treatment in service for anxiety due to unit problems and post-service psychiatric treatment after the death of his daughter. The examiner noted the diagnoses of PTSD contained in the VA treatment records, but stated that there was no indication that a thorough evaluation of the Veteran's symptoms, to include delineation of a stressor, had been undertaken. When asked about his alleged service-related stressors, the Veteran reported that "some guy went out to jog and stepped on a land mine." He then indicated that it was a friend of his and that he heard the land mine explode and saw dust, but did not see anything else occur. He also reported being shot at by Koreans and seeing soldiers regularly get beat up and cut. The examiner noted that the Veteran's description of the events was rather vague and that there appeared to be some inconsistencies in his report of the events across various interviews. The examiner concluded that the discrepancies would lead one to doubt the veracity of the Veteran's report, but stated that even had the alleged stressors indeed happened as described, none would fulfill the DSM-IV criterion necessary for a diagnosis of PTSD. The examiner also found that the Veteran did not report the full constellation of symptoms necessary for a diagnosis of PTSD, nor did he report the frequency or severity of the symptoms or indicate that he experienced them at the level that would be necessary for a diagnosis of PTSD. The results of psychometric testing were also indicative of symptom severity exaggeration. Ultimately, the examiner concluded that the Veteran did not meet the full diagnostic criteria for PTSD and that his unremitting and extensive substance abuse likely played a role in his mood symptoms, none of which were related to military service. In September 2011, the Board noted that the Veteran's representative had raised the issue of secondary service connection and thus remanded the matter to obtain an opinion as to the likelihood that a service-connected disability had caused or aggravated the Veteran's diagnosed psychiatric disability. In September 2011, the Veteran's claims folder was reviewed by a VA clinician who opined that it was not at least as likely as not that the Veteran's psychiatric disorder, specifically his dysthymic disorder, was caused or aggravated by a service-connected disability, to include coronary artery disease, migraine headaches, diabetes mellitus, and/or diabetic nephropathy with renal dysfunction. Rather, the VA reviewer indicated that likely, the only exacerbating factor concerning the Veteran's dysthymia was his ongoing substance dependence. The reviewer went on to state that, according to the DSM-IV, in order for a psychiatric disability to be secondary to a general medical condition, it is required that an etiological or causal mechanism be established between the medical disorder and the psychiatric diagnosis. The reviewer listed the example of Huntington's Chorea, in which a clear neuropsychological mechanism exists for the causation of a depressive disorder. The reviewer then stated that no such mechanism exists in the case coronary artery disease, migraine headaches, diabetes mellitus and associated renal dysfunction. Another medical opinion concerning the question of secondary service connection was obtained in January 2013. The VA clinician reviewed the claims folder, to specifically include all previous VA examination and opinion reports and the Veteran's lay statements. Upon consideration of all evidence of record, the VA reviewer opined that it was less likely than not that the Veteran's diagnosed dysthymic disorder was proximately due to or the result of service-connected coronary artery disease, migraine headaches, diabetes mellitus and associated renal dysfunction. As support for her opinion, the reviewer noted that the Veteran was not diagnosed with a mental disorder in service or within a year of discharge from service, pointing out that a diagnosis of dysthymic disorder was not rendered until 1994 after his wife and daughter had died. She noted that the Veteran's mental health symptoms of his dysthymic disorder were deemed by the 1996 VA examiner to be related to his chronic and active substance abuse, which opinion was reiterated by independent evaluators in 2008, 2009, and 2010. The reviewer noted that although the Veteran had reported that he no longer drank alcohol or used cocaine or amphetamines, he continued to report daily cannabis use. The reviewer stated that research confirms that substance use can cause symptoms of mood instability, such as depression, feelings of anxiety, and also disturbances in sleep and motivation. The reviewer went on the state that given that the Veteran was using some type of drug every time he was seen for mental health treatment and that his symptoms seemed to remain consistent as his drug use remained consistent, it was logical to conclude that the Veteran's mental health symptoms, diagnosed as dysthymic disorder, were directly related to his drug use. The reviewer also noted that none of the providers who treated the Veteran for mental health problems had indicated that his psychiatric symptoms were caused or aggravated by any physical condition. The reviewer indicated that if the conditions were related, one would need to see a temporal relationship between the onset of the two conditions, with emergence of the two conditions around the same time frame, or the worsening of one condition upon the worsening of the other, or the alleviation of one condition upon the alleviation of the other. As no such pattern was demonstrated by the evidence of record, the review found there to be no evidence to suggest that the Veteran's mental health condition was caused by or aggravated by any service-connected disability. As an additional note, the reviewer stated that there is no known biological or etiological mechanism linking dysthymic disorder to any medical condition, including coronary artery disease, migraine headaches, diabetes mellitus, or diabetic nephropathy. The reviewer noted that that fact had been clearly stated by another clinical psychologist and indicated her agreement with the previous psychologist's opinion. B. Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) 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, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Turning first to the Veteran's claim of service connection for PTSD, the Board notes that service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See Cohen v. Brown, 10 Vet. App. 128, 138 (1997); 38 C.F.R. § 3.304(f) (2012). Unless it is determined that a veteran was engaged in combat with the enemy and the claimed stressor is related to such combat, the Veteran's alleged stressor(s) generally must be established by official service records or other credible supporting evidence. Cohen, supra; Doran v. Brown, 6 Vet. App. 283 (1994); 38 C.F.R. § 3.304(f). However, if the claimed non-combat stressor is related to the veteran's "fear of hostile military or terrorist activity" and a VA or VA-contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor so long as there is not 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. 38 C.F.R. § 3.304(f)(3) (2012). As to whether service connection is warranted for PTSD, the Board finds that the evidence fails to confirm a current diagnosis of PTSD according to the DSM-IV criteria, as required by 38 C.F.R. § 4.125. Specifically, no VA examiner has provided an Axis I diagnosis of PTSD and the evidence fails to demonstrate that the Veteran has been diagnosed as having PTSD related to a claimed in-service stressor. While the Board does not dispute that the post-service treatment records variously record an Axis I diagnosis of PTSD and PTSD by history, it does not appear that those diagnoses were based upon an alleged in-service stressor, as opposed to the death of the Veteran's wife and daughter. Further, none of the VA examiners found the Veteran's alleged in-service stressors to satisfy criterion A of the DSM-IV criteria for a diagnosis of PTSD and the September 2010 VA examiner stated that there was no indication that any PTSD diagnosis contained in the record had been based on a thorough evaluation of the Veteran's symptoms, to include delineation of a stressor. While a "PTSD diagnosis by a mental-health professional must be presumed . . . to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor," there clearly exists an exception to his general rule when "evidence shows to the contrary." Cohen, 10 Vet. App at 140. In the instant case, the Board finds that the VA examiners' opinions that the Veteran does not meet the DSM-IV criteria for a diagnosis of PTSD based on an alleged in-service stressor outweighs the diagnoses of PTSD contained in the record, as the VA examiners clearly indicated that the Veteran's alleged in-service stressors were not adequate to support a diagnosis of PTSD and the VA treatment records contain no discussion of the Veteran's alleged in-service stressors. Rather, the January 1994 treatment record notes the Veteran's psychosocial stressor to be the death of his daughter and upon being admitted for psychiatric treatment in September 1995, his stressors were noted to be the deaths of his wife and daughter. Thus, although the Veteran was diagnosed as having PTSD at that time, it is apparent that any such diagnosis was rendered based not upon an alleged in-service stressor, but rather upon the death of the his daughter and wife. Furthermore, the VA examiners were all in agreement that Veteran did not present the full constellation of symptoms necessary for a diagnosis of PTSD, and the September 2010 VA examiner found that the Veteran did not report the frequency or severity of symptoms or indicate that he experienced them at the level that would be necessary for a diagnosis of PTSD. Accordingly, the Board finds that the competent and probative evidence of record fails to establish that the Veteran has a current diagnosis of PTSD that conforms to the DSM-IV criteria and is based on an alleged in-service stressor. As such, there is no basis upon which to award service connection for PTSD. See 38 U.S.C.A. § 5121(a); Cohen, 10 Vet. App at 138; 38 C.F.R. § 3.304(f). With regard to the Veteran's diagnosed dysthymic disorder, nothing in the VA treatment records or examination reports can be read as suggesting that the Veteran's dysthymic disorder, or any other recorded Axis I diagnosis, may be etiologically related to service. Rather, the evidence suggests that the Veteran's psychiatric symptoms are related to the death of his wife and daughter and exacerbated by his substance abuse. Notably, the June 1996 VA examiner stated his opinion that the Veteran's current psychiatric situation appeared to have more to do with the loss of his wife and daughter, as well as with the loss of his job, physical integrity, and concern for his health and welfare. In January 2000, the Veteran's increased psychiatric symptoms were attributed to his anniversary date, the holidays, and discord at home. The June 2008 VA examiner found that the Veteran's mood disturbance was very likely exacerbated by his chronic substance abuse and upon examination in September 2010, it was concluded that the Veteran's unremitting and extensive substance abuse likely played a role in his mood symptoms, which symptoms were not related to military service. Lastly, the January 2013 VA reviewer stated her opinion that given that the Veteran was using some type of drug every time he was seen for mental health treatment and that his symptoms seemed to remain consistent as his drug use remained consistent, it was logical to conclude that the Veteran's mental health symptoms, diagnosed as dysthymic disorder, were directly related to his drug use. Further, the Veteran's STRs fail to suggest the presence of a psychiatric disorder in service. While they do note that the Veteran presented with anxiety stemming from unit problems and was referred to mental hygiene, they do not reflect that the Veteran was indeed seen in mental hygiene or that he continued to have psychiatric complaints. Notably, at the time of his February 1971 separation examination, the Veteran was clinically evaluated as being psychiatrically normal and he denied all significant medical history, save for stomach troubles and associated sleep problems. Nervous trouble of any sort, depression, and excessive worry were specifically denied on the on the accompanying report of medical history. Further, mental status examination conducted at the time of June 1974 hospitalization revealed only a report of auditory hallucinations when on drugs. In light of this evidence, the Board finds that there is simply no evidence of a nexus between the Veteran's dysthymic disorder, or any other diagnosed Axis I disability, and service. See Davidson, supra. The Veteran has also asserted his belief that his dysthymic disorder and associated psychiatric symptoms are secondary to service-connected disabilities. A disability may be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. (The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310 during the pendency of the Veteran's claim. See 71 Fed. Reg. 52744 -47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310 (2012)). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's 1995 ruling in Allen, it was made clear in the comments to the regulation that the 2006 changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which strongly suggests that the revision amounts to a substantive change in the regulation. Given what appear to be substantive changes, and because the Veteran's claims were pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the revision, which version favors the claimant. 38 C.F.R. § 3.310 (2006). Upon review of the evidence of record, the Board also finds there to be no basis upon which to award service connection for an acquired psychiatric disability as secondary to a service-connected disability. In this regard, the Board finds particularly probative the September 2011 and January 2013 VA clinicians' opinions. Notably, the VA clinicians stated that according to the DSM-IV, in order for a psychiatric disability to be secondary to a general medical condition, it is required that an etiological or causal mechanism be established between the medical disorder and the psychiatric diagnosis, which mechanism was lacking in the case of coronary artery disease, migraine headaches, diabetes mellitus and associated renal dysfunction. The January 2013 VA clinician also indicated that if the Veteran's psychiatric and service-connected conditions were related, one would see a temporal relationship between the onset of the two conditions, or the worsening of one condition upon the worsening of the other, or the alleviation of one condition upon the alleviation of the other. As these patterns were not demonstrated by the evidence of record, the reviewer found there to be no evidence to suggest that that the Veteran's mental health condition was caused or aggravated by any service-connected disability. The Board also notes that none of the providers who treated the Veteran for mental health problems have indicated that his psychiatric symptoms were caused or aggravated by any physical condition. Rather, the evidence of record, to include the September 2011 and January 2013 VA clinicians' opinion reports, suggests that any increase or aggravation of the Veteran's current psychiatric symptomatology is related to his substance abuse. The January 2013 reviewer specifically stated that research confirms that substance use can cause symptoms of mood instability, such as depression, feelings of anxiety, and also disturbances in sleep and motivation. Further, multiple clinicians have attributed the Veteran's psychiatric disability to the death of his daughter and wife. In consideration of the evidence of record, the Board finds that the Veteran does not have an acquired psychiatric disorder that was caused made worse by any service-connected disability. Although the Veteran believes that his psychiatric disability has been aggravated by a service-connected disability, the Board notes that generally etiology of dysfunctions and disorders is a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion with regard to his acquired psychiatric disorder, especially in light of the medical opinions to the contrary. See Jandreau, supra. For the foregoing reasons, the Board finds that the claim of service connection for an acquired psychiatric disorder, to include PTSD, must be denied. In reaching this conclusion, the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting service connection for an acquired psychiatric disorder, to include PTSD under any theory advanced by the Veteran. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102 (2012). III. Service Connection - Hypertension As noted in the introduction, analysis of the Veteran's claim of service connection for hypertension requires that Board to consider whether service connection may be warranted for hypertension as directly related to service, as secondary to an acquired psychiatric disorder, or as secondary to service connected diabetes mellitus. Further, because hypertension is considered a chronic disease that may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty, the Board must also consider whether the Veteran is entitled to service connection for hypertension on a presumptive basis. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). At the outset, the finds that service connection for hypertension is not warranted as secondary to an acquired psychiatric disorder. This is so because there is no legal basis upon which to award service connection for disabilities that are claimed as secondary to a disability that is not service connected. As entitlement to service connection for an acquired psychiatric disorder has not been established, service connection for hypertension, secondary to an acquired psychiatric disorder is not warranted as a matter of law. See 38 C.F.R. § 3.310. Turning to the question of whether service connection is warranted for hypertension as directly related to service, the evidence of record shows that the Veteran has a current diagnosis of hypertension. A review of the Veteran's STRs fails to indicate that the Veteran had hypertension in service. At the time of enlistment, his blood pressure was recorded as 136/88 and the Veteran denied having high blood pressure on the accompanying report of medical history. He was treated in service in 1969 for complaints of chest pain, at which time his blood pressure was noted to be 140/90. A January 1971 treatment note recorded the Veteran's blood pressure as 120/100. At the time of his February 1971 separation examination, the Veteran's blood pressure was noted to be 124/87. He again denied having high blood pressure on the accompanying report of medical history. The Veteran had a period of post-service hospitalization in 1974, during which he was diagnosed as having headaches and drug dependence. The Veteran's medical history was silent for complaints or treatment of high blood pressure. A September 1985 post-service treatment record states that the Veteran was known to be hypertensive since 1978 and was then taking medication to control his blood pressure. At that time, his blood pressure was noted to be 154/112. An October 1985 treatment entry records the Veteran's assertion that he was first given medication for hypertension in 1970. The entry further states that high blood pressure was not formally treated until 1982. A physical examination of the Veteran completed in March 1987 recorded a diagnosis of hypertension and indicated its date of onset to be 1982. During his 2003 hearing, the Veteran testified that he first sought post-service treatment for hypertension in 1972 at a facility within the Pittsburgh, Pennsylvania, VA healthcare system (HCS), at which time he was placed on medication to control his blood pressure. The Veteran stated that he has been on medication since that time. The Veteran was afforded a VA examination September 2010, during which time he reported in-service treatment for hypertension and stated that he was treated for hypertension at a VA medical center in 1972. The examiner reviewed the claims folder, but found no evidence in the Veteran's STRs to support of in-service diagnosis of hypertension. The examiner noted that the STRs lacked the serial blood pressure readings taken over a several-day period to document sustained hypertension. In this regard, the Board notes that single readings of elevated blood pressure, even during service, do not reflect hypertensive vascular disease. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note(1). Ultimately, the examiner concluded that the Veteran's hypertension was not related to service as there was no diagnosis of hypertension in service or within one year of discharge from service. Based upon a review of the record and consideration of the Veteran's lay statements, the Board finds that although the Veteran has a current diagnosis of hypertension, service connection is not warranted because the evidence fails to demonstrate that the Veteran's hypertension either began in service or is otherwise related to service. The evidence also fails to establish that the Veteran's hypertension became manifest to a degree of 10 percent or more within one year of leaving qualifying military service. In this regard, the Board has considered the Veteran's statements that he was treated for hypertension within a year of service. However, a review of the record fails to support the Veteran's assertion in this regard. Notably, records from the Pittsburgh VAHCS dated in 1974 fail to contain any suggestion that the Veteran was being treated for hypertension at the time, or that he had previously been treated for hypertension. Moreover, none of the post-service VA treatment records from the VAHCS where the Veteran reported receiving treatment and being placed on medication for hypertension in 1972 support his assertion. Indeed, the earliest indication of hypertension is 1978, well more than a year after service and other records suggest that the Veteran was not diagnosed with hypertension until 1982. Perhaps most informative is the October 1985 treatment entry that specifically states that high blood pressure was not formally treated until 1982. Given this evidence, the Board finds that the Veteran's assertions that he was treated for hypertension within a year of service are not credible and the Board finds no reason to remand the matter for the AOJ to search for VA treatment records dated within a year of the Veteran's discharge from service. This evidence also negates any finding of continuity of symptomatology since service. See 38 C.F.R. § 3.303(b). Accordingly, in view of the findings on examination in September 2010, which are uncontradicted in the record, and in light of the fact that the Veteran's hypertension was not diagnosed until 1978 at the earliest, and more likely not until 1982, a finding of service connection for hypertension as directly related to service is not warranted. The Board is aware that the September 2010 VA examiner's negative nexus opinion is lacking somewhat in rationale. However, there is no requirement imposed on a medical examiner to provide detailed reasons for an opinion. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Indeed, "there is no reasons or bases requirement imposed on examiners." Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Rather, an adequate medical report must rest on correct facts and reasoned medical judgment so as to inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding, in the context of weighing one medical opinion with another, that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion"); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) ("An opinion is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994))); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In the instant case, there is no indication that the examiner failed to consider any piece of relevant evidence before providing his opinion regarding the likelihood that the Veteran's hypertension is directly related to service. The examiner clearly considered the Veteran's STRs, which showed elevated blood pressure readings, but failed to contain serial readings necessary to diagnosis hypertension, and the post-service medical evidence showing diagnosis of and treatment for hypertension. To the extent that the examiner did not consider the Veteran's lay statements regarding treatment within a year of separation from service, those statements have been determined to be not credible and thus have no probative value. The Board also finds no reason to discount the medical opinion based on the clinician's expertise and qualifications as a medical professional. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (holding that VA medical examinations must be '"provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions'") (quoting 38 C.F.R. § 3.159(a)(1) (2012)). Further, given the absence of contrary evidence in this case, the Board need not weigh the VA examiner's opinion against other evidence. Indeed, there is no evidence, other than the Veteran's own assertions, to suggest that his hypertension is attributable to service. As such, the Board finds that the lack of a more detailed rationale does not render September 2010 opinion inadequate. Overall, the Board finds that none of the competent and probative evidence of record establishes a nexus between the Veteran's current hypertension and his active military service. As noted above, the VA examiner in September 2010 opined against an association between the Veteran's hypertension and military service. Further, the credible evidence of record suggests that the Veteran's hypertension was not diagnosed or treated until at least seven, and more likely twelve, years after service. Thus, the Board finds that there is no basis to establish service connection for hypertension as directly related to service, as a crucial element of service connection has not been shown. See Davidson, supra (service connection requires evidence of a nexus between the claimed in-service disease or injury and the present disability); see also Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability that still exists currently). The Board also concludes that the evidence of record does not support a finding of service connection for hypertension as a presumptive chronic disease. Indeed, there is simply no evidence to suggest that the Veteran's hypertension manifested itself as a chronic disease within one year of discharge from service. See 38 C.F.R. §§ 3.307, 3.309. As to any contention by the Veteran that because he had an elevated blood pressure reading in service, his current hypertension must therefore be etiologically related to service, the Board notes that generally etiology of dysfunctions and disorders is a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion with regard to his hypertension, especially in light of the fact that the evidence fails to demonstrate the onset of that disability in service. See Jandreau, supra. Turning to the question of whether the Veteran's service-connected diabetes mellitus may have caused or aggravated the Veteran's hypertension, the Board notes that post-service treatment records document that the Veteran was first diagnosed with diabetes mellitus in 2000 or 2001. In May 2011, the Veteran was afforded a VA examination for the purpose of determining whether his hypertension was caused or aggravated by his diabetes mellitus. The examiner noted that a review of the claims folder evidenced a diagnosis of hypertension that predated by many years the Veteran's diagnosis of diabetes mellitus. The examiner also indicated that the Veteran had an elevated microalbumin urine of 1432.2, which would be considered a moderate elevation by renal service standard. It was also noted that the Veteran had a preserved normal BUN (blood urea nitrogen) test at 13 and creatine at 0.8. The examiner also noted that a renal consult indicated that the Veteran was in a non-nephrotic range of proteinuria. Upon review of the evidence of record, the VA examiner concluded that the Veteran's diabetic nephropathy was not at a level of severity that would affect or cause an increase in his blood pressure. The examiner further stated that because the proteinuria that was present is not in a non-nephrotic range, it would not be a causal or aggravating factor for the Veteran's hypertension. Lastly, the examiner stated that because the Veteran's hypertension predated the onset of his diabetes mellitus by many years, his hypertension was not result of or caused by his diabetes mellitus. Concerning the first aspect of a secondary service connection claim, the VA examiner rendered an opinion that the Veteran's hypertension was not a manifestation of his diabetes mellitus because evidence of hypertension predated the Veteran's diagnosis of diabetes. With respect to whether the Veteran's diabetes mellitus exacerbates his hypertension, the examiner noted that the Veteran did not demonstrate severe enough diabetic nephropathy for the Veteran's diabetes mellitus to cause an aggravation (that is, a chronic worsening) of the Veteran's hypertension. In consideration of the evidence of record, the Board finds that the Veteran does not have hypertension that was proximately caused or made worse by his service-connected diabetes mellitus. The VA examination report detailed above is highly probative evidence for deciding the claim, and is, indeed, uncontradicted by any other evidence of record. The examiner reviewed the claims folder and the opinion is based on all of the evidence of record, to include the Veteran's VA treatment records and guidance set forth in the M21-MR. In sum, the Board finds that the probative evidence of record fails to demonstrate that the Veteran's hypertension is proximately due to or the result of the Veteran's service-connected diabetes mellitus. Nor does the evidence show that the Veteran's diabetes mellitus has aggravated his hypertension. Further, while the Veteran is service connected for disabilities, he had not asserted, nor does the evidence suggest, an association between his hypertension and any service-connected disability other than his diabetes mellitus and related diabetic nephropathy. Accordingly, service connection for hypertension is therefore not warranted on a secondary basis. See Allen, supra; 38 C.F.R. § 3.310. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, and to include as secondary to service-connected disabilities, is denied. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder and as secondary to a service-connected disability, is denied. ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs