Citation Nr: 1312819 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 06-06 858 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, and schizophrenia. 2. Entitlement to service connection for bilateral knee replacements. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran had active military service from January 1969 to January 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from February and August 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran testified before the undersigned Veterans Law Judge at a January 2010 hearing conducted via videoconference. A transcript of the hearing is of record. The Board notes that the Veteran has perfected appeals regarding the issues of entitlement to service connection for major depressive disorder and entitlement to service connection for an acquired psychiatric disorder, to include PTSD and schizophrenia. As the scope of the claim of entitlement to service connection for an acquired psychiatric disorder includes major depressive disorder, the claim has been recharacterized above as entitlement to service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder, and schizophrenia. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). This case was previously before the Board in October 2009, May 2010, and May 2012 when it was remanded for further development. FINDINGS OF FACT 1. An acquired psychiatric disorder, diagnosed as psychosis, schizoaffective disorder, and major depressive disorder, was not present in service or until years thereafter and is not etiologically related to any incident of service. 2. A bilateral knee disability was not present in service or until years thereafter, and is not etiologically related to any incident of service. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include PTSD, psychosis, major depressive disorder, and schizophrenia, was not incurred in or aggravated by active service, and was not manifest to a degree of 10 percent within one year of separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. Bilateral knee disability was not incurred in or aggravated by active service and service incurrence may not be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (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, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the VCAA duty to notify was satisfied by way of letters sent to the appellant in April 2004, May 2004, and August 2004 that fully addressed notice elements and were sent prior to the initial AOJ decision in this matter. The letters informed the appellant of what evidence was required to substantiate the claims and of the appellant's and VA's respective duties for obtaining evidence. After the initial AOJ decision in this matter the Veteran was provided notice that a disability rating and an effective date for the award of benefits would be assigned if service connection was awarded in a letter dated in May 2010. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of her or his claim and given ample time to respond, but the AOJ also readjudicated the case by way of a supplemental statement of the case issued in December 2012 after the notice was provided. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records and records regarding an application for Social Security Administration benefits have been obtained and associated with the claims file. The Board notes that attempts were made to obtain treatment records from Methodist Hospital and Winnona Hospital. These attempts were unsuccessful and the Veteran was notified that these records could not be obtained. The Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. The appellant was afforded VA medical examinations in May 2004, October 2011, and July 2012. In October 2009 the Board remanded the Veteran's claims for the Veteran to be afforded a hearing before a Veterans Law Judge. In May 2010 the Board remanded the Veteran's claims and relevantly ordered that the Veteran be contacted to identify medical providers. On remand in May 2012 the Board ordered that additional VA treatment records be obtained and associated with the claims file and that the Veteran be afforded VA examinations. The Board notes that the Veteran was afforded a hearing before the undersigned Veterans Law Judge via videoconference. In a letter dated in May 2010 the Veteran was requested to provide additional information regarding medical providers. Lastly, additional VA treatment records have been obtained and associated with the claims file and the Veteran was afforded VA medical examinations in July 2012. Therefore, based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's remands. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Court held in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010) that there are two duties imposed by 38 C.F.R. § 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked-are not impacted by the Veteran's receipt of a VCAA-compliant notice letter. Here, during the hearing, although the Veterans Law Judge did not explicitly note the bases of the prior determinations or note the elements that were lacking to substantiate the Veteran's claims, the Veteran's representative demonstrated actually knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran had an acquired psychiatric disorder and bilateral knee disorder related to his service. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.) Accordingly, the Veteran is not shown to be prejudiced on this basis. In addition, the Veterans Law Judge sought to identify any pertinent, outstanding evidence that might have been overlooked. The Veterans Law Judge specifically asked the Veteran where he received his treatment after service. Accordingly, the Veteran is not shown to be prejudiced on this basis. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection for PTSD requires medical evidence of a current diagnosis of PTSD, credible supporting evidence that the claimed in-service stressor(s) occurred, and a link between the current diagnosis and the claimed in-service stressor(s). 38 C.F.R. § 3.304(f); See also Cohen v. Brown, 10 Vet. App. 128 (1997). Effective July 13, 2010, the regulations governing adjudication of service connection for PTSD were liberalized, in certain circumstances, with respect to the evidentiary standard for establishing the required in-service stressor. For cases pending before VA as of that date, the following regulation applies: If a stressor claimed by a [V]eteran is related to the [V]eteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the [V]eteran'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 [V]eteran's service, the [V]eteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a [V]eteran 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 [V]eteran 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 [V]eteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f)(3); see 75 Fed. Reg. 39843 (July 13, 2010). Service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1112, 1110, and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). Psychosis or arthritis can be service-connected on such a basis if manifest to a degree of 10 percent or more within one year from the date of separation from service. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604(Fed.Cir.1996). A. Acquired Psychiatric Disorder The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder, and schizophrenia. The Veteran contends that he has had depression ever since a gunshot wound while in service on leave. Service treatment records do not reveal any complaint, diagnosis, or treatment for any psychiatric disorder. In January 2004 the Veteran was diagnosed with mood disorder due to general medical condition. In March 2004 the Veteran was diagnosed with depression due to chronic pain. In another March 2004 treatment note, the Veteran was indicated to have felt depressed for the prior three to four months which he attributed to progressively increased pain in the neck, arms, back and stomach. He had been on morphine for the pain. The Veteran reported one other period of depression when he was hospitalized after a gunshot wound in service. The chronic pain was worse since a motor vehicle accident in 2001. In June 2004 the Veteran was again diagnosed with depression. In August 2004 the Veteran reported that his depression stopped and then came back. In September 2004 the Veteran was diagnosed with schizoaffective disorder. In another treatment note, dated in September 2004, the Veteran was noted to have a history of major depressive disorder, PTSD, and chronic pain. The Veteran was also noted to have a diagnosis of psychotic disorder in a treatment note dated in September 2004. The Veteran was diagnosed with psychosis (rule out schizoaffective, depressed type), depression, and rule out PTSD in treatment notes dated in May 2005, June 2005, and July 2005. In May 2005 and December 2005 the Veteran was noted to be diagnosed with schizoaffective disorder. In addition, the Veteran's VA treatment notes reveal consistent treatment for psychiatric disorders and that the Veteran was treated as an inpatient for psychiatric disorders. In September 2011 the Veteran reported that he first had audio hallucinations in his early 20's four to five years after his friend died in a boiler explosion during his time in the military. The provider indicated that "It is unclear by history, but it sounds as if patient had onset of psychosis in his early 20s . . ." Also in September 2011 the Veteran indicated that he had been hearing one voice for the last twenty to thirty years that tells him to kill himself. The Veteran was diagnosed with schizoaffective disorder, with psychotic features; major depressive disorder, with psychotic features; and psychosis NOS. In October 2011 the Veteran was diagnosed with psychosis, rule out schizoaffective disorder, and rule out cognitive disorder NOS. The Axis III included diagnoses diabetes mellitus, hypertension, coronary artery disease, hearing loss, osteoarthritis, and obstructive sleep apnea. In October 2011 neuropsychiatric testing revealed a primary diagnosis of schizoaffective disorder with depression. In October 2011 the Veteran was afforded a VA Compensation and Pension (C&P) psychiatric examination. The examiner noted that the Veteran had inpatient treatment in April 2011 and September 2011 for psychiatric disabilities. The examiner noted that the Veteran was diagnosed with major depressive disorder, schizoaffective disorder, and psychosis in September 2011 and that in October 2011 the Veteran's diagnosis of schizoaffective disorder with depressed mood was confirmed by neuropsychiatric testing. After examination the Veteran was diagnosed with schizoaffective disorder, depressed type. However, the examiner did not render an opinion regarding the etiology of the Veteran's disability. In November 2011 the examiner provided an addendum regarding the etiology of the Veteran's PTSD. The examiner noted that the Veteran did not meet the criteria for a diagnosis of PTSD and that he did not have any symptoms associated with PTSD at that time. In addition, the examiner noted that the Veteran's current psychiatric symptomology was related to the Veteran's diagnosis of schizoaffective disorder based on the manifestation of psychotic and depressive symptoms. In January 2012 it was noted that even though the Veteran reported psychotic symptoms his presentation was noted to not be consistent with any objective evidence of psychosis. It was reported that the onset of symptoms at a later age and their atypical presentation argues against the possibility of a major psychotic disorder. The Veteran was noted to be a poor historian, including in a treatment note dated in March 2012. In June 2012 the Veteran was diagnosed with schizoaffective disorder. The Veteran was afforded a VA medical examination in July 2012. The Veteran was noted to not be diagnosed with PTSD but to be diagnosed with schizoaffective disorder. The Veteran was noted to have total occupational and social impairment due to his psychiatric disability. After discussion of the Veteran's pre-service social history the Veteran was noted to report that he had problems in basic training because he could not swim and was scared to go into the water. He reported a stressor of his best friend being killed in boiler explosion aboard the USS Goldsborough. He also reported the stressor of being shot while on leave in Gary, Indiana. He stated that he and his friend were in a cab and his friend was trying rob the cab driver. The driver shot his friend three times and hit him once. Thereafter the Veteran's post-service history was discussed. The Veteran denied pre-military and military mental health treatment. He was noted to be treated by VA for physical health problems since April 1995 and that his records were completely silent for any problems with mental health disorders until December 2003. The examiner discussed the Veteran's subsequent mental health treatment in detail. After a review of the symptoms, the Veteran was not diagnosed with PTSD. The examiner stated that the Veteran had no symptoms of PTSD. The examiner reported that the Veteran reported a traumatic stressor (death of friend while in Navy), but no current mental health symptoms that would indicate a diagnosis of PTSD. The examiner stated that the Veteran had never been diagnosed with PTSD, despite repeated evaluations, and that he was also not diagnosed with PTSD after extensive psychological testing, results of which were reported in a treatment note dated in September 2004. The examiner concluded that this absence of PTSD symptoms is also wholly consistent with the Veteran's previous C&P exam dated in October 2011. The examiner noted that the Veteran did have auditory and visual hallucinations which he claimed were related to the death of this friend; however, visual and auditory hallucinations are not symptoms of PTSD. Furthermore, the examiner noted that visual hallucinations and audio hallucinations of a particular event due not indicate that the particular event caused the symptoms. He had no symptoms of re-experiencing, avoidance, or increased arousal other than sleep impairment which was attributable to his schizoaffective disorder. The examiner found that the Veteran met the criteria for a diagnosis of schizoaffective disorder, depressive type. However, the examiner rendered the opinion that the Veteran's schizoaffective disorder was less likely than not related to the Veteran's claimed stressor of a friend's death in service or his military service in general. The examiner found that the Veteran's schizoaffective disorder less likely than not had its onset during service and less likely than not had its onset within the first three years of his discharge from the Navy. The examiner discussed the timing of the onset of the disability as well as whether the Veteran's stressor of seeing his friend burned to death would cause schizoaffective disorder, regardless of the date of onset. The examiner found that the onset of the Veteran's schizoaffective disorder was difficult to determine because the Veteran had given numerous accounts of the timing of the onset of his symptoms. Therefore, the examiner indicated that the Veteran's report of the timing of the onset of his disorder cannot be used as a credible or reliable method of establishing when the disorder first began. The examiner reported that there appeared to be only two sources of evidence outside of the Veteran himself that can be used to establish date of onset. The first is the Veteran's military service records, which are entirely absent for complaints of or treatment of mental health problems, including his separation exam. The second source is the Veteran's sister who was present at one of the Veteran's hospitalizations and who stated that the Veteran symptoms began 20 years prior to the hospitalization (treatment note dated in October 2004) which would indicate that the onset was in about 1984 when the Veteran was about 34 years old. This later date of onset would seem to be consistent with the Veteran's good social, educational, and occupational functioning that the Veteran reported he experienced in the first few years after his discharge from the Navy, as he reported to the current C&P examiner in July 2012. The examiner explained that DSM-IV states that "[t]he typical age at onset of [s]chizoaffective [d]isorder is early adulthood, although onset can occur anywhere from adolescence to late in life." Thus, a later onset (several years after his discharge from the Navy) would be entirely consistent with established medical literature. The examiner opined on the cause of the disorder itself, regardless of date of onset. The examiner found that the fact that the Veteran's current audio and visual hallucinations have content related to the Veteran's friend who died in the Navy does not in any way suggest or indicate that the traumatic event actually caused the disorder. For example, of note was the fact that the Veteran currently reports he often sees a 3-headed vampire, a visual hallucination which obviously is not caused by any particular event involving a 3-headed vampire. The examiner explained that in short, the nature or content of any given hallucinatory experience or delusional belief does not indicate the cause of a particular mental health disorder. The examiner found that in the Veteran it is unclear whether his claimed stressor actually occurred, or if his claim of the event is, in itself, a delusion, which would be only a symptom of his schizoaffective disorder itself, not a statement of the cause of the disorder. The Board finds that entitlement to service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder, and schizophrenia. Service treatment records do not reveal any complaint, diagnosis, or treatment for any psychiatric disorder. Post service treatment records reveal that the Veteran has been variously diagnosed with psychiatric disorders including mood disorder, depression, and schizoaffective disorder, and psychosis. Neuropsychiatric testing has identified the Veteran as having a primary diagnosis of schizoaffective disorder. The post service treatment records reveal that the Veteran has been noted to have a history of PTSD; however, the treatment notes do not reveal a diagnosis of PTSD based upon the Veteran's stressors. Upon examination in October 2011 the Veteran was diagnosed with schizoaffective disorder, depressed type, and in a subsequent addendum, dated in November 2011, the examiner noted that the Veteran did not meet the criteria for a diagnosis of PTSD. Upon examination in July 2012 the Veteran was again noted to not have a diagnosis of PTSD. The examiner diagnosed the Veteran with schizoaffective disorder and rendered the opinion that the Veteran's disorder was not related to his active military service. The examiner noted that although the Veteran reported treatment for physical disorders by VA since April 1995, his records were completely silent for any problems with mental health disorders until December 2003. The examiner reasoned that the timing of the onset of the Veteran's schizoaffective disorder was consistent with the Veteran's good social, educational, and occupational function that he reported in the first few years after his separation from service. Further, the examiner reasoned, based upon the typical age of onset of schizoaffective disorder being early adulthood although onset could occur anywhere from adolescence to late in life, that a later onset (several years after his discharge from the Navy) would be entirely consistent with established medical literature. In addition, the examiner explained that the content of audio and visual hallucinations do not suggest or indicate that a traumatic event actually caused the disorder. The Board notes that in September 2011 the Veteran reported that he first had audio hallucinations in his early 20's four to five years after his friend died in a boiler explosion during his time in the military and that a provider indicated that "It is unclear by history, but it sounds as if patient had onset of psychosis in his early 20s . . ." In addition, the Veteran has contended that he has been depressed since suffering a gunshot wound while in service on leave. However, in January 2012 it was noted that even though the Veteran reported psychotic symptoms his presentation was noted to not be consistent with any objective evidence of psychosis. In addition, the Board notes that by his report, the Veteran's hallucinations did not being until after one year post separation from service, the Veteran reported good social, educational, and occupational functioning for the first few years after separation from service, and the Veteran's sister was noted to report that his symptoms did not begin until 20 years prior to October 2004, well after separation from active service. As such, the Board finds that the preponderance of the evidence is against a finding that the Veteran's acquired psychiatric disorder had its onset in service, was related to his active service, or that psychosis manifested to a degree of 10 percent or more within one year of separation from service, service connection is denied. B. Bilateral Knee Replacements The Veteran seeks entitlement to service connection for bilateral knee replacements. The Veteran contends that his knee disability began after he struck his knee in service. In addition, in a statement received in April 2004 the Veteran contended that his knee problems began after his gunshot wound. Service treatment records reveal that the Veteran struck his knee in September 1969 and was noted to have a sore knee with a normal X-ray. In November 2000 the Veteran reported that he had knee problems ever since he slipped and fell in the bilges of the USS Goldsborough. In a statement dated in January 2005 the Veteran reported that his knee condition was due to a fall. Treatment record reveal that the Veteran was diagnosed with degenerative joint disease of the knees in March 2000, May 2000, and September 2000 and moderately severe degenerative joint disease of the knees in December 2000, January 2001, February 2001, and March 2001. In July 2001 the Veteran was noted to have been admitted for rehabilitation for his bilateral knee arthroplasties. In a July 2001 disability examination in regard to the Veteran's application for SSA benefits it was noted that the Veteran was status post bilateral total knee replacement secondary to arthritis degenerative type. An X-ray examination in March 2002 revealed stable bilateral total knee arthroplasty prosthesis. There was interval resolution of suprapatellar soft tissue swelling. A March 2003 X-ray examination of the knees revealed no change since one year prior. The knees were stable status post bilateral knee total arthroplasty prosthesis. In May 2004 the Veteran again underwent an X-ray of the knees. The X-ray revealed bilateral total knee arthroplasties with no acute fracture or dislocation. In May 2004 the Veteran was afforded a VA C&P examination. The Veteran reported that his knees began hurting in 1985 and that he had no trauma to either. The knees were noted to eventually fail conservative treatment and led to total arthroplasty in 2001. He used a walker or cane to help with balance and weakness in his lower legs and keep him from buckling. He stated that he can only walk about a block and had to quit his job as an executive chef in 2001 when he had his knee operation. He reported that he took Morphine on a constant basis. After physical examination the examiner noted that the Veteran had an onset of knee pain without traumatic event that eventually required a total knee replacement which has done only moderately well. In March 2005 the Veteran underwent an X-ray of the knees. The X-ray revealed stable bilateral bicomponent knee prostheses without periprosthetic lucency, acute fracture, or dislocation. Stable dystrophic calcification and minimal osteoarthritic changes of the patella were noted. In September 2011 the Veteran reported that he fell on his knees and then his back after his ship moved while in service. In July 2012 the Veteran was afforded a VA medical examination. The Veteran was noted to be diagnosed with residuals of bilateral total knee replacement. The Veteran stated that his ship boiler exploded and had to go to dry dock and he injured his knees in the chaos. He reported that he fell. He had bilateral total knee replacement in 2001 and he stated, "they seem like they are alright now. They did a good job." He stated that they "do alright." "They don't bother me that much." He stated he is able to walk on them okay most of the time, but they can become aggravated if he tries to walk on them too long. He reported that sometimes they might cause him pain if he "over does it" such as walking a long distance, but he adds that "I can't really do that anymore due to my back." He denied that they will hurt if he is just at rest (except for very rarely). He denied that his knees feel unstable or feel like they ever lock up. The Veteran reported that if he is on his feet for a prolonged period of time he might get more pain in his bilateral knees. Range of motion tests were performed and the Veteran was found to have less movement than normal in both knees. The Veteran was noted to have reduced muscle strength of 4/5 in both knees and was reported to have had knee replacement surgery in 2001. X-rays of the knees were performed and were noted to reveal intact bilateral knee replacement hardware without evidence of complication. There were small right effusions. After examination the examiner rendered the opinion that the Veteran's knee disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that service treatment records reveal that in September 1969 he fell into a "Desuper heater (?) in #1 fire room banging knee. Swelling and tenderness noted". In September 1969 the Veteran was seen with a "sore knee" and x-ray examination was noted to be negative. The Veteran was treated with an Ace wrap, moist heat, and aspirin. The examiner noted that there was no other mention of knee problems in his service treatment records. The examiner explained that this incident was an acute knee injury that appears to be consistent with a superficial, minor injury and the natural course of the described injury would most likely be that it would completely resolve within a few days. The examiner further stated that this assessment is supported by the fact that no other service treatment records regarding knee problems could be found. The examiner stated that the Veteran had bilateral knee replacement many years later in 2001 (32 years later) and that no correlation can reasonably be made to these incidents. Based upon this rationale the examiner rendered the opinion that it is less likely than not that his knee condition (residuals of bilateral knee replacement) is due to his in service incident of "banging" his knee in 1969. The Board finds that entitlement to service connection for bilateral knee replacements is not warranted. The Board acknowledges that the Veteran was treated for a sore knee after striking it in service in 1969 and that post service the Veteran underwent bilateral knee replacement. However, the preponderance of the evidence is against a finding that the Veteran's in service injury to the knee is related to the Veteran's post service knee replacements. After examination in July 2012, the examiner rendered the opinion that the Veteran's in service knee injury was an acute injury that would have resolved in days and that this was supported by the lack of further treatment in service. As such, the examiner rendered the opinion that the Veteran's post service bilateral knee replacements were not related to the Veteran's knee injury in service. Neither is it shown that arthritis was manifest within one year of service discharge. Therefore, as the preponderance of the evidence is against a finding that the Veteran's bilateral knee replacements are related to the Veteran's active service, service connection is denied. ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, and schizophrenia, is denied. Service connection for bilateral knee replacements is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs