Citation Nr: 1312959 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 07-01 068 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, including duodenitis, irritable bowel syndrome, and diverticulitis, and to include as secondary to the acquired psychiatric disorder. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for an acquired psychiatric disorder, not including PTSD, but including depression, anxiety, psychosis, personality disorder, schizophrenia, and alcohol abuse. 4. Entitlement to service connection for right ear hearing loss. 5. Entitlement to service connection for left ear hearing loss. 6. Entitlement to service connection for tinnitus. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1959 to May 1966. This appeal comes before the Board of Veterans' Appeals (Board) from November 2005 and June 2007 rating decisions of Department of Veterans Affairs (VA) Regional Offices (ROs), which denied the benefits sought on appeal. The Veteran testified before the undersigned Acting Veterans Law Judge (AVLJ) at a Board videoconference hearing from the RO in San Antonio, Texas, in March 2010. A transcript of the hearing is associated with the claims file. In June 2010, the Board reopened the final disallowed claim for service connection for a stomach disorder and remanded the appeal for further development. The RO certified this appeal to the Board in July 2012. Subsequently, additional evidence was added to the record. However, the Veteran's representative waived his right to have the RO initially consider this evidence in a statement dated in September 2012. 38 C.F.R. §§ 20.800, 20.1304 (2012). In December 2012, the case was returned to the Board. Upon reviewing the claims folder, the Board referred the acquired psychiatric disorder claim to a specialist for an advisory medical opinion. See 38 U.S.C.A. § 7109(a) (West 2002); 38 C.F.R. § 20.901 (2012); see also generally Wray v. Brown, 7 Vet. App. 488, 493 (1995). This opinion was obtained in January 2013 and is included in the claims file. It is noted that the Veteran and his representative have been given the opportunity to provide any comments with respect to this opinion and those comments have been included in the claims file. The Veteran's Virtual VA paperless claims file was also reviewed in preparing this decision and remand. The issue of entitlement to service connection for a gastrointestinal disorder, including duodenitis, irritable bowel syndrome, and diverticulitis, and to include as secondary to the service-connected acquired psychiatric disorder, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In July 2012, following the March 2012 Substantive Appeal, but prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeal pertaining to the claim of entitlement to service connection for PTSD was requested. 2. The Veteran's current acquired psychiatric disorder, to include depression and anxiety, is shown to be causally or etiologically related to his active military service. 3. The Veteran's right ear sensorineural hearing loss first manifested in service with a continuity of symptoms after service. 4. The Veteran's left ear sensorineural hearing loss first manifested many years after service and was not caused or aggravated by any aspect of service, to include exposure to noise from artillery or small arms fire. 5. The Veteran's tinnitus first manifested many years after service, and was not caused or aggravated by any aspect of service, to include exposure to noise from artillery or small arms fire. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal pertaining to the claim of entitlement to service connection for PTSD have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. The criteria for service connection for an acquired psychiatric disorder, to include depression and anxiety, but not including psychosis, personality disorder, schizophrenia, and alcohol abuse, have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. The criteria for service connection for sensorineural hearing loss of the right ear have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2012). 4. The criteria for service connection for sensorineural hearing loss of the left ear have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2012). 5. The criteria for service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). (CONTINUED ON THE NEXT PAGE) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Withdrawal of PTSD Claim The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the Veteran or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran has withdrawn his appeal pertaining to his PTSD claim in a July 2012 statement, following the March 2012 Substantive Appeal that perfected his appeal. Hence, there remain no allegations of errors of fact or law for appellate consideration on this issue. Accordingly, the Board does not have jurisdiction to review this issue, and it is dismissed. II. Veterans Claims Assistance Act of 2000 (VCAA) Initially, the Board notes that it is granting service connection for an acquired psychiatric disorder and right ear hearing loss in this decision. Thus, there is no prejudice to the Veteran and no further discussion of the VCAA is required. The Board will only address the duty to notify and assist for the left ear hearing loss and tinnitus claims in the discussion below. 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, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA must notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements apply to all five elements of a service connection claim. The five elements are: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that the content requirements of a duty to assist notice letter have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in February 2007 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claims, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The letter also provided the Veteran with information concerning the evaluations and effective dates that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). This letter was provided prior to the initial RO adjudication of his claims in the June 2007 rating decision. Accordingly, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. For all of these reasons, the Board concludes that the appeal may be adjudicated without a remand for further notification. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. His STRs, personnel records, and post-service VA and private treatment records have been obtained. VA has obtained all relevant, identified, and available evidence, and has notified the Veteran of any evidence that could not be obtained, including records of the award of Social Security Administration (SSA) benefits and records of care at the VA Medical Center (VAMC) in Corpus Christi, Texas, which were no longer available. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. The record indicates that the Veteran participated in a VA audiological examination in November 2010, the results of which have been included in the claims file for review. The examination involved a review of the claims file, a thorough examination of the Veteran, and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the examination is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claims. Furthermore, the Veteran was afforded a Board hearing in March 2010. A Board member has two duties at a hearing: (1) a duty to fully explain the issues still outstanding that are relevant and material to substantiating the claim, and (2) a duty to suggest that a claimant submit evidence on an issue material to substantiating the claim when the record is missing any evidence on that issue or when the testimony at the hearing raises an issue for which there is no evidence in the record. See 38 C.F.R. § 3.103(c)(2) (2012); Bryant v. Shinseki, 23 Vet. App. 488, 492, 496 (2010). Here, during the Board hearing, the AVLJ specifically noted the issues, in pertinent part, as service connection for hearing loss and tinnitus. The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative then asked the Veteran questions regarding the elements of the claims that were lacking to substantiate the claims for benefits. In addition, the AVLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with the hearing requirements, nor 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 for benefits. As such, the Board finds that the AVLJ complied with the aforementioned hearing duties, and that any error in notice provided during the Veteran's hearing constitutes harmless error. The Board is also satisfied as to substantial compliance with its June 2010 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). This included scheduling the Veteran for a VA examination. The Veteran was afforded this VA audiological examination in November 2010. This also included obtaining the Veteran's SSA records. The AMC requested the SSA records, and, in July 2010, SSA informed the AMC that the SSA records had been destroyed. The remand also directed the AMC to obtain the Veteran's VA clinical records from 1972 to 1976 and from February 2008 to the present, particularly from the VAMC in Corpus Christi, Texas. In July 2010, the VAMC in Corpus Christi, Texas, responded to the AMC's request for records, indicating that they did not have any treatment records for the Veteran during the period from 1972 to 1976. The Veteran was informed of the unavailability of these SSA and VA records in a letter dated in September 2010, and he was provided the opportunity to submit the records. The Veteran did not submit the records, and, in September 2010, the AMC made a Formal Finding regarding the unavailability of these records. The AMC did obtain the Veteran's recent VA records dated since February 2008, and these records were associated with his Virtual VA claims file. The remand also included readjudicating the Veteran's claims, which was accomplished by the AMC in the March 2012 Supplemental Statement of the Case (SSOC). Thus, the Board finds that there has been substantial compliance with its remand directives. Id. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claims. Therefore, no further assistance to the Veteran with the development of evidence is required. III. Service Connection A. General Regulations and Statutes Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110 , 1131; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d). Certain chronic diseases, such as psychoses and organic disease of the nervous system, including sensorineural hearing loss, but not tinnitus, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). See Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995 (characterizing high frequency sensorineural hearing loss as an organic disease of the nervous system). Regarding only the psychoses and sensorineural hearing loss claims, service connection may be awarded for a "chronic" disorder when: (1) a chronic disorder manifests itself and is identified as such during the active military service (or within the presumption period under 38 C.F.R. § 3.307, and the Veteran presently has the same disorder); or (2) a disorder manifests itself during the active military service (or during the presumptive period), but is not identified until later, there is a showing of continuity of symptomatology after the military discharge, and medical evidence relates the symptomatology to the Veteran's present disorder. 38 C.F.R. § 3.303; see Walker v. Shinseki, 708 F.3d 1331 (the theory of continuity of symptomatology can be used only in cases involving those disorders explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). For the showing of chronic disease during the active military service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If a chronic disease is shown during the active military service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service-connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). However, continuity of symptoms is required where a disorder is noted during the active military service, but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); see Walker, 708 F.3d at 1331. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. B. Acquired Psychiatric Disorder The Veteran seeks service connection for an acquired psychiatric disorder, not including PTSD, but including depression, anxiety, psychosis, personality disorder, schizophrenia, and alcohol abuse. As noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. The claims file contains several psychiatric diagnoses. However, following a review of the Veteran's recent treatment records, the VA psychiatrist, in a January 2013 medical opinion, found that the Veteran's current psychiatric disorder was manifested by depression and anxiety. The psychiatrist found that the Veteran had a history of diagnoses of depression, anxiety, depression with psychosis, dysthymic disorder, personality disorder, and schizophrenia. However, the psychiatrist found that the Veteran's current psychiatric diagnoses were depression and anxiety. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's service personnel records show that he was inducted into the Army for a term of two years but reenlisted for three years in the regular Army in March 1960. He completed basic and advanced infantry training and was assigned to an artillery unit in Kentucky. He received punishment at a Special Court Martial in June and October 1960 for misconduct involving alcohol abuse, disobeying orders, and absence without official leave. Subsequently, the Veteran's military performance improved significantly, and he was promoted to Specialist 4 with duties as a cook. He was granted a waiver of the previous Court Martial record, and he reenlisted in May 1963. He received a temporary promotion to Specialist 5 in September 1963. In January 1964, the Veteran requested an overseas assignment with a preference for duty in Germany. In October 1964, the Veteran was transferred to an engineering unit in Korea where he served until November 1965. His spouse and child did not accompany him on this overseas assignment. In December 1964, February 1965, June 1965, and August 1965, the Veteran received non-judicial punishment for absence from his place of duty, improper performance of duty, and on one occasion for wrongfully defecating on a barracks floor. Punishment included a reduction in pay grade to Specialist 4. In January 1966, the Veteran was hospitalized at a military facility at his duty station in the United States following a suicide attempt. The circumstances, treatment, and the results of a Line of Duty/Misconduct investigation are discussed further below. In April 1966, the Veteran was awarded non-judicial punishment in the form of restriction to post and extra duties for a simple assault on his spouse and failure to pay just debts. In April 1966, the Veteran's commanding officer declined to recommend him for reenlistment because of the assault, indebtedness, and failure to respond to counseling. The Veteran received a general discharge under honorable conditions at the end of his term of enlistment. The Veteran's STRs are silent for any symptoms, diagnoses, or treatment of an acquired psychiatric disorder with the exception of an April 1966 examination discussed below. The Veteran denied any symptoms of frequent trouble sleeping, nervous trouble, loss of memory, nightmares, depression or excessive worry on physical examinations in April 1963 and March 1966. The military examiners noted no psychiatric abnormalities. Nonetheless, as noted above, the Veteran received military discipline during his first year of service but his performance thereafter improved significantly. In a March 1976 statement, the Veteran noted that after receiving punishment in the stockade, he got married and decided to become a good soldier. However, after transfer to duty in Korea, his supervising sergeant gave him "a very hard time" and his temporary promotion was removed. He noted that he began to abuse alcohol and failed to write home to his spouse in the United States. He noted that upon his return to the United States, he continued alcohol abuse and experienced persistent marital discord. Records of a Line of Duty/Misconduct Investigation and associated medical treatment records showed that the Veteran's spouse left him in January 1966. Two days later, the Veteran attempted suicide by turning on natural gas in his home and consuming excess alcohol and unidentified pills. He called his spouse to express suicidal intent and his spouse notified law enforcement officers in time to intervene. The Veteran was hospitalized and physically recovered from the attempted gas poisoning without complications. The attending physician noted the Veteran's reports of being picked-on by supervisors in Korea and that the reduction in pay grade caused him to go deeply in debt. The physician noted that the Veteran was oriented with no evidence of a psychosis and was no longer suicidal or depressed but rather was "disgusted" with himself. The Veteran and his spouse provided statements to a military investigating officer in February 1966. The spouse stated that since his return from overseas, the Veteran consumed alcohol in excess, did not enjoy interacting with his children, and made physical threats to her. Shortly after moving out with the children, a relative informed her of the Veteran's intent to commit suicide and called for help to intervene. After the incident, the spouse returned home. The Veteran noted in his statement that his reasons for the attempt were personal and were not related to his service. He noted that he wanted to reenlist in the Army. He noted that he had mixed feelings and concern about his financial situation. He began drinking with a neighbor who was leaving soon for Vietnam and when he discovered that his spouse had left home, he called a relative and his spouse to say that he was tired of living. He noted that he had consumed about one case of beer prior to turning on the gas. The investigating officer concluded that the suicide attempt was in response to marital and financial problems and that the Veteran was intoxicated at the time of the attempt. He concluded that the incident was not in the line of duty and was due to the Veteran's misconduct. In April 1966, a military psychiatrist noted that he examined the Veteran upon his admission to the hospital in January 1966 and again in April 1966. The psychiatrist concluded that the suicide gesture was a manipulative attempt to affect reconciliation with his spouse that had subsequently occurred. The psychiatrist noted that there was no evidence at any time of a mental illness. He concluded that the Veteran was free of mental disease, defect, and derangement and was able to distinguish right from wrong and adhere to the right. Service treatment and personnel records are silent for any reports by the Veteran or other information related to deaths of two fellow soldiers or sexual assaults. In April 1966, the Veteran's commanding officer declined to recommend the Veteran for reenlistment, citing persistent indebtedness and multiple arrests for assaults on his spouse. Personal counseling produced no significant changes. The commanding officer concluded that the Veteran's conduct of his personal affairs were a burden on his company and the Army. The Veteran received a general discharge under honorable conditions at the end of his term of enlistment and not for medical reasons. In summary, the Veteran did attempt suicide in January 1966 after his spouse left him, and he had multiple stressors in his life during his active military service, which included demotion, indebtedness, marital strife, legal trouble due to assaults on his spouse and alcohol abuse. Thus, the second element of service connection has been satisfied. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the only medical nexus opinions of record are positive. In this regard, in a March 2010 letter, a private consulting psychologist reviewed the service and post service personnel, adjudicative, and medical treatment records that were provided to him for review in connection with the Veteran's VA appeal. He did not examine the Veteran. The psychologist noted the Veteran's history of minor disciplinary infractions, but did not discuss sexual assaults or the deaths of fellow soldiers. The psychologist noted the suicide attempt in January 1966 and concluded without explanation or justification that the Army responded to this only with discipline and a pejorative psychiatric evaluation in April 1966. The psychologist inaccurately stated that the Veteran made a second suicide attempt in service in December 1966. This statement appears to be in error as the Veteran was discharged in May 1966 and did attempt suicide again in December 1976, ten years later. The psychologist noted that treatment starting in 1976 was indicative of a depressive disorder and the onset of psychiatrically related irritable bowel syndrome. The psychologist concluded that the Veteran's depression had its onset in service and was consistent after service. The psychologist did not address the Veteran's denial of symptoms on his discharge physical examination, the absence of any psychiatric diagnosis in service, and the gap of ten years prior to the first diagnosis in 1976. The Veteran failed to report for a VA examination that was scheduled in February 2012. Accordingly, in December 2012, the Board referred the acquired psychiatric disorder claim to a specialist for an advisory medical opinion. This opinion was obtained in January 2013. Following a review of the claims file, the VA psychiatrist found that the Veteran's current acquired psychiatric disorder consisted of depression and anxiety. Regarding the current diagnoses of depression and anxiety, the psychiatrist determined that these psychiatric disorders manifested in service and were caused by stress during the Veteran's active military service. The examiner reasoned that the Veteran attempted suicide during his active military service. He also had multiple stressors, including but not limited to his spouse left him, demotion, indebtedness, marital strife, legal trouble due to assaults on his spouse, alcohol abuse, and medical issues. The psychiatrist also based his opinion on a review of the Veteran's claims file and over ten years of experience as a psychiatrist. Regarding the Veteran's prior, historical diagnoses of depression with psychosis, dysthymic disorder, personality disorder, schizophrenia, and alcohol abuse, the psychiatrist found that there was not enough evidence to support the conclusion that these prior diagnoses were first manifested in service or alternatively were caused during the Veteran's active military service. In summary, the only medical nexus opinions of record are positive concerning the Veteran's current depression and anxiety. There are no contrary medical opinions in the claims file. The Veteran's lay statements, along with the VA and private treatment records, support the medical nexus opinions. Accordingly, given the STRs, the Veteran's lay statements, and the post-service medical opinions that attribute the Veteran's current depression and anxiety to his active military service, service connection for an acquired psychiatric disorder, to include depression and anxiety, is warranted. The evidence favors the Veteran's claim and there is no evidence holding otherwise. Service connection for an acquired psychiatric disorder, to include depression and anxiety, but not including psychosis, personality disorder, schizophrenia, and alcohol abuse, is granted. C. Right Ear Hearing Loss The Veteran seeks service connection for right ear sensorineural hearing loss. Regarding the first element of service connection (i.e., a current diagnosis), for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In Hensley v. Brown, 5 Vet. App. 155 (1993), the Court held that, even though disabling hearing loss - that is, according to the requirements of 38 C.F.R. § 3.385 - may not have been demonstrated at time of separation from service, a Veteran may still establish his entitlement to service connection for a current hearing loss disorder by showing he now satisfies the threshold minimum requirements of § 3.385 and by submitting evidence that his current hearing loss disorder is related to his military service. See also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Audiometric testing during the Veteran's November 2010 VA audiological examination revealed the following pure tone threshold levels, in decibels, in the indicated frequencies: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 60 65 70 The November 2010 VA examiner also diagnosed the Veteran with normal to severe sensorineural hearing loss on the right. Thus, the Veteran has a current right ear hearing loss diagnosis, and he has satisfied the first element of service connection. Regarding the second element of service connection (i.e., an in-service incurrence), the Veteran's service personnel records showed that he completed basic and advanced infantry training and was assigned to infantry, artillery, and armored units. He was not in combat. Even though he performed duties as a cook for a significant portion of his service, the Board concludes that the Veteran was likely exposed to small arms and artillery fire in training and field exercises. The Veteran's STRs document that a whispered voice test at his November 1959 military entrance examination was normal (15/15) in the right ear. The Veteran was afforded another audiogram at his May 1963 reenlistment examination. In this regard, prior to November 1967, audiometric results were reported in standards set forth by the American Standards Association (ASA). Those are the figures on the left of each column and are not in parentheses. Since November 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses. Audiometric testing during his May 1963 reenlistment examination revealed the following pure tone threshold levels, in decibels, in the indicated frequencies: HERTZ 500 1000 2000 3000 4000 RIGHT 20 (35) 10 (20) 25 (35) -- 60 (65) Thus, based on the converted figures in parentheses, the Veteran displayed hearing loss in his right ear at the May 1963 reenlistment examination. The May 1963 examiner assigned a profile of two for hearing, indicating that commanders should consider some activity limitations. Although the Veteran performed duties as a cook before and after this evaluation, it is not clear in the records whether any limitations were imposed. A personnel data form prepared in February 1964 noted "defective hearing." In a March 1966 discharge physical examination, an audiogram showed normal hearing in the right ear at all tested frequencies. No profile was assigned. The Veteran denied any ear "trouble." Post-service, in March 1976, a VA examiner noted the Veteran's report of difficulty hearing in the right ear. An evaluator noted mild right ear hearing loss with good speech discrimination and concluded that the Veteran did not require hearing aids. In July 1976, a VA examiner noted the Veteran's report of difficulty hearing in the right ear. No audiograms were obtained on either occasion. The RO received the Veteran's claim for service connection for right ear hearing loss in December 2006. The Veteran submitted a report of a private hearing examination obtained the same month. The examiner noted the Veteran's reports of exposure to high noise levels from artillery and small arms fire in service and current difficulties using the telephone, and understanding conversations while riding in an automobile and when sleeping on his left side. On examination, his right ear was clear. An audiogram showed puretone thresholds at 500, 1000, 2000, 3000 and 4000 Hz as 55, 60, 70, 80 and 80 decibels at the respective frequencies on the right. The speech discrimination score on the right was 84 percent. The examiner did not comment directly on the origin of the hearing loss but the examiner did not reject the noise exposure in service as non-contributory. In March 2007, a VA audiologist noted the Veteran's reports of exposure to noise in service and post service work as a laborer, factory worker, and truck driver with no significant noise exposure. The audiologist noted that the Veteran could not or would not cooperate with an audiometric test. In November 2007, a private audiologist submitted a medical statement summarizing the Veteran's October 2007 outpatient treatment visit. The audiologist noted the Veteran's reports of prior noise exposure, and diagnosed the Veteran with moderate to severe sensorineural hearing loss in the right ear. His speech discrimination score was 60 percent on the right. No ear abnormalities were shown. No opinion was provided. In January 2008, another VA audiologist noted a review of the claims file and the same noise exposure history and current symptoms. On examination, puretone thresholds at the specified frequencies were 25, 25, 65, 75 and 80 decibels on the right. The speech discrimination score on the right was 86 percent. The audiologist noted that the discharge audiometric test in March 1966 was normal and concluded that the current hearing loss did not originate in service. The audiologist did not note or comment on the test results and profile shown in 1963 and 1964. In March 2008, the Veteran submitted a copy of a general information article written by the Veterans Health Administration chief research and development officer. The official noted that one in seven noise-exposed Veterans have hearing loss or tinnitus, and described several on-going research projects. In an April 2008 RO hearing and a March 2010 Board hearing, the Veteran and his spouse stated that they were married in 1961 and described an event when the Veteran fell asleep on his left side in his automobile, did not hear an alarm, and missed the birth of a child. He stated that he reported hearing loss in the right ear to VA physicians when he was hospitalized for other reasons in 1976, but did not seek medical attention for hearing loss until 2006. Nevertheless, he stated that he experienced hearing loss since his exposure to small arms and artillery fire in the military service. The Veteran acknowledged that he underwent audiograms in 1963 and 1966, but did not recall the results. He again stated that he had no significant noise exposure after service in several occupations but continued to experience hearing loss. In June 2010, the Board determined that the 2008 VA examination was not adequate as the examiner did not address evidence of hearing loss on the right in 1963. The Board instructed the RO to obtain another examination and opinion on the origin of the disorders. In November 2010, another VA audiologist noted a review of the service and VA treatment records and accurately summarized the in-service and post-service history of noise exposure and symptoms reported by the Veteran including occasional dizziness. The audiologist noted that the Veteran denied any history of ear infections or organic ear disease, and currently had difficulty hearing conversation particularly in high background noise. On examination, puretone thresholds at the specified frequencies were 25, 25, 60, 65, and 70 decibels on the right. The speech discrimination score on the right was 86 percent. The audiologist diagnosed normal to severe sensorineural hearing loss on the right. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's current right ear hearing loss was less likely as not (less than 50/50 probability) caused by or a result of military acoustic trauma. The audiologist noted the normal hearing on entry on active duty, the right ear deficit measured in 1963, and the normal audiogram at the time of discharge. The audiologist noted that the 1963 right ear measurement was not confirmed in subsequent testing and concluded that the sudden shift was temporary or inaccurate. The audiologist explained that had the right ear measurement of 60 decibels at 4000 Hz in the 1963 test been accurate, the current level of right ear hearing loss would be much worse that shown on the current examination because of the effects of aging and some civilian noise exposure after service. Moreover, the Veteran did not report any hearing difficulties on the 1966 discharge examination as would be likely if he had difficulty hearing in the right ear. Nonetheless, the Board notes that there is evidence for and against the notion that the Veteran's right ear hearing loss began during his active military service. The Veteran and his spouse are competent to report the Veteran's hearing difficulty in his right ear in 1961 and thereafter. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The reports are credible as they are consistent with the measurement of 60 decibels at 4000 Hz obtained in 1963. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), and in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A military physician at the time appeared to rely on the results and assigned an appropriate limitation of activities. Ten years later in 1976, the Veteran again reported right ear hearing loss that was qualitatively evaluated as mild without measurements at specific frequencies to confirm or deny the accuracy of the 1963 or 1966 testing. The Board places some probative weight on the opinion of the VA audiologist in 2010, who noted that the 1963 result could have represented a temporary deficit and that if it were accurate and permanent, a more severe degree of loss on the right would be evident in current examinations. On review of the three post service audiograms, the measurement of the right ear at 4000 Hz has become more severe over the years, deteriorating from 60 decibels in service to 70 and 80 decibels in more recent examinations. Therefore, even though inconsistent and unconfirmed, there was some credible lay and medical evidence of hearing loss in the right ear at 4000 Hz in service that warranted consideration for restriction of duties. There is credible evidence of a continuity of right ear deficits in 1976, and well-measured and more severe degradation starting in 2006. Therefore, resolving all doubt in favor of the Veteran, the Board concludes that service connection for the sensorineural hearing loss of the right ear only is warranted as there was evidence of onset in service with a continuity of symptoms after service. Organic diseases of the nervous system, to include sensorineural hearing loss, is recognized under 38 C.F.R. § 3.309(a) as a chronic disorder. Thus, the theory of continuity of symptomatology can be applied to the Veteran's right ear sensorineural hearing loss, and the service connection claim can be granted under this theory. 38 C.F.R. § 3.303; see Walker, 708 F.3d 1331 (the theory of continuity of symptomatology can be used only in cases involving those disorders explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). As there is an approximately equal balance of evidence both for and against the claim, the "benefit of the doubt" rule is for application, and the Board will grant service connection for right ear hearing loss. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for right ear hearing loss is granted. D. Left Ear Hearing Loss The Veteran seeks service connection for left ear sensorineural hearing loss. Audiometric testing during the Veteran's November 2010 VA audiological examination revealed the following pure tone threshold levels, in decibels, in the indicated frequencies: HERTZ 500 1000 2000 3000 4000 LEFT 25 20 25 40 30 The November 2010 VA examiner also diagnosed the Veteran with mild sensorineural hearing loss on the left. Thus, the Veteran has a current left ear hearing loss diagnosis, and he has satisfied the first element of service connection. Regarding the second element of service connection (i.e., an in-service incurrence), the Veteran's service personnel records showed that he completed basic and advanced infantry training and was assigned to infantry, artillery, and armored units. He was not in combat. Even though he performed duties as a cook for a significant portion of his service, the Board concludes that the Veteran was likely exposed to small arms and artillery fire in training and field exercises. The Veteran's STRs document that a whispered voice test at his November 1959 military entrance examination was normal (15/15) in the left ear. The Veteran was afforded another audiogram at his May 1963 reenlistment examination. In this regard, prior to November 1967, audiometric results were reported in standards set forth by the ASA. Those are the figures on the left of each column and are not in parentheses. Since November 1, 1967, those standards have been set by the ISO-ANSI. In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses. Audiometric testing during his May 1963 reenlistment examination revealed the following pure tone threshold levels, in decibels, in the indicated frequencies: HERTZ 500 1000 2000 3000 4000 LEFT 20 (35) 10 (20) 10 (20) -- 10 (15) Thus, based on the converted figures in parentheses, the Veteran displayed normal hearing in his left ear at the May 1963 reenlistment examination. The examiner assigned a profile of two for hearing (presumably for the Veteran's right ear, which did display hearing loss at that examination), indicating that commanders should consider some activity limitations. Although the Veteran performed duties as a cook before and after this evaluation, it is not clear in the records whether any limitations were imposed. A personnel data form prepared in February 1964 noted "defective hearing." In a March 1966 discharge physical examination, an audiogram showed normal hearing in the left ear at all tested frequencies. No profile was assigned. The Veteran denied any ear "trouble." As previously mentioned, the third element of direct service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the only medical opinions of record are negative. Specifically, the Veteran submitted a report of a private hearing examination obtained in December 2006. The examiner noted the Veteran's reports of exposure to high noise levels from artillery and small arms fire in service, and current difficulties using the telephone and understanding conversations while riding in an automobile and when sleeping on his left side. On examination, his left ear was clear bilaterally. An audiogram showed puretone thresholds at 500, 1000, 2000, 3000 and 4000 Hz as 40, 45, 45, 52, and 52 decibels at the respective frequencies on the left. The speech discrimination score on the left was 80 percent. The examiner did not comment directly on the origin of the hearing loss, but the examiner did not reject the noise exposure in service as non-contributory. In March 2007, a VA audiologist noted the Veteran's reports of exposure to noise in service and post service work as a laborer, factory worker, and truck driver with no significant noise exposure. The audiologist noted that the Veteran could not or would not cooperate with an audiometric test. In November 2007, a private audiologist submitted a medical statement summarizing the Veteran's October 2007 outpatient treatment visit. The audiologist noted the Veteran's reports of prior noise exposure, and diagnosed the Veteran with moderate to severe sensorineural hearing loss in the left ear. His speech discrimination score was 88 percent on the left. No ear abnormalities were shown. No opinion was provided. In January 2008, another VA audiologist noted a review of the claims file and the same noise exposure history and current symptoms. On examination, puretone thresholds at the specified frequencies were 25, 25, 25, 45, and 35 decibels on the left. The speech discrimination score on the left was 90 percent. The audiologist noted that the discharge audiometric test in March 1966 was normal and concluded that the current hearing loss did not originate in service. In March 2008, the Veteran submitted a copy of a general information article written by the Veterans Health Administration chief research and development officer. The official noted that one in seven noise exposed Veterans have hearing loss or tinnitus, and described several on-going research projects. In an April 2008 RO hearing and a March 2010 Board hearing, the Veteran and his spouse stated that they were married in 1961 and described an event when the Veteran fell asleep on his left side in his automobile, did not hear an alarm, and missed the birth of a child. He stated that he had experienced hearing loss since his exposure to small arms and artillery fire in service. The Veteran acknowledged that he underwent audiograms in 1963 and 1966 but did not recall the results. He again stated that he had no significant noise exposure after service in several occupations but continued to experience hearing loss. In November 2010, another VA audiologist noted a review of the service and VA treatment records and accurately summarized the in service and post-service history of noise exposure and symptoms reported by the Veteran. The audiologist noted that the Veteran denied any history of ear infections or organic ear disease and currently had difficulty hearing conversation particularly in high background noise. On examination, puretone thresholds at the specified frequencies were 25, 20, 25, 40, and 30 decibels on the left. The speech discrimination score on the left was 92 percent. The audiologist diagnosed normal to mild sensorineural hearing loss on the left. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's current left ear hearing loss was less likely as not (less than 50/50 probability) caused by or a result of military acoustic trauma. The audiologist noted the normal hearing on entry on active duty, and the normal audiogram at the time of discharge. On the Veteran's separation Report of Medical History in 1966, the examiner pointed out that the Veteran also did not report any issues with his ears or hearing. Here, the only medical nexus opinions of record are negative. The VA examiners clearly reviewed the STRs and other evidence in the claims folder. They provided medical opinions that are supported by and consistent with the evidence of record. There is no positive evidence to the contrary of these opinions in the claims file. The VA and private treatment records do not provide contrary evidence. For all of these reasons, service connection for left ear hearing loss is not warranted. The Board notes that the Veteran reports that his left ear hearing loss began in service and has continued since that time. However, the Veteran's current recollections are not consistent with the entire evidentiary record. The audiometric readings in service are a more accurate means to measure hearing acuity, and those findings greatly outweigh the Veteran's subjective perceptions of decreased left ear hearing acuity. Additionally, in 1976, the Veteran reported decreased right ear hearing acuity but did not report decreased left ear hearing acuity. Furthermore, he currently recalls having tinnitus since service but, in 1976, he specifically denied tinnitus. As addressed more fully below, his current recollections many decades later are inaccurate and deemed not credible. Additionally, the Board finds that the Veteran is not entitled to presumptive service connection for his left ear sensorineural hearing loss. As stated above, the earliest post-service medical treatment records are dated from 2006, and the Veteran was separated from the active duty in 1966. No diagnosis of left ear sensorineural hearing loss was made within one year of the Veteran's military discharge. Thus, the presumption for service connection for chronic diseases does not apply. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In reaching this decision, the Board has considered the Veteran's and his spouse's lay statements, and the articles submitted by them, in support of the Veteran's claim. Overall, the Board finds that the recollections of decreased left ear hearing acuity since service are not credible when viewed against the entire evidentiary record. The opinions of the Veteran and his spouse, as well as the evidentiary value of the articles, are greatly outweighed by the opinion of the November 2010 VA audiologist who, in addition to having more expertise and training to speak to the issue at hand, has provided an analysis based upon the specific facts of this case and actual audiometric readings. It is important to point out that the Board does not find that the lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson, 581 F.3d at 1313, quoting Buchanan, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Rather, the lay statements are found to be not credible because they are inconsistent with the evidence of record, which fails to show left ear hearing loss during his active military service, which does not show left ear hearing loss until four decades after his separation from the active duty, and which contains only negative medical nexus opinions. For the reasons set forth above, the Board finds that the lay statements asserting that the Veteran's left ear hearing loss has been present since his active military service are not credible. Therefore, these statements do not warrant a grant of service connection or a determination that further development of the medical evidence is required. All other evidence of record, aside from the lay statements in support of this current claim, is unfavorable to the claim for service connection for left ear hearing loss. The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert, 1 Vet. App. at 49. The Veteran's claim of entitlement to service connection for left ear sensorineural hearing loss is not warranted. E. Tinnitus The Veteran seeks service connection for tinnitus. As noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. On VA examination in November 2010, the Veteran was diagnosed with tinnitus. Thus, the Veteran has satisfied the first element of service connection. As stated above, the second element of direct service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's service personnel records showed that he completed basic and advanced infantry training and was assigned to infantry, artillery, and armored units. He was not in combat. Even though he performed duties as a cook for a significant portion of his service, the Board concludes that the Veteran was likely exposed to small arms and artillery fire in training and field exercises. The Veteran's STRs are silent for any documentation of tinnitus. The records reveal no complaints or treatment related to tinnitus. Tinnitus was not reported on his military separation examination. The Veteran's active military service ended in May 1966. As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the only medical nexus opinions of record are negative. Specifically, at a July 15, 1976 VA examination, the Veteran denied any tinnitus. The Veteran submitted a report of a December 2006 private hearing examination. The examination did not refer to the Veteran's tinnitus. In March 2007, a VA audiologist noted the Veteran's reports of exposure to noise in service and post-service work as a laborer, factory worker, and truck driver with no significant noise exposure. The Veteran reported occasional dizziness and moderate tinnitus especially at night that interfered with sleep. The audiologist noted that the Veteran could not or would not cooperate with an audiometric test. In November 2007, a private audiologist submitted a medical statement summarizing the Veteran's October 2007 outpatient treatment visit. The audiologist noted the Veteran's reports of prior noise exposure and tinnitus. No ear abnormalities were shown. No medical opinion was provided. In January 2008, another VA audiologist noted a review of the claims file and the same noise exposure history and current symptoms. The Veteran reported that his tinnitus interfered with his communication. The audiologist noted that the discharge audiometric test in March 1966 was normal and concluded that the current tinnitus did not originate in service. In March 2008, the Veteran submitted a copy of a general information article written by the Veterans Health Administration chief research and development officer. The official noted that one in seven noise-exposed Veterans have hearing loss or tinnitus, and described several on-going research projects. In an April 2008 RO hearing and a March 2010 Board hearing, the Veteran and his spouse stated that the Veteran had experienced tinnitus since his exposure to small arms and artillery fire in service. The Veteran acknowledged that he underwent audiograms in 1963 and 1966, but did not recall the results. He again stated that he had no significant noise exposure after service in several occupations, but continued to experience tinnitus. In November 2010, another VA audiological examination was provided. Following a physical examination of the Veteran and a review of the claims file, the VA examiner determined that the Veteran's current tinnitus was less likely as not (less than 50/50 probability) caused by or a result of military acoustic trauma. The examiner reasoned that there was no evidence of tinnitus in the Veteran's STRs. On the Veteran's separation Report of Medical History in 1966, the examiner pointed out that the Veteran also did not report any issues with his ears or hearing. Here, the only medical nexus opinions of record are negative. The VA examiners clearly reviewed the STRs and other evidence in the claims folder. They provided medical opinions that are supported by and consistent with the evidence of record. There is no positive evidence to the contrary of these opinions in the claims file. The VA and private treatment records do not provide contrary evidence. For all of these reasons, service connection for tinnitus is not warranted. Furthermore, the Board notes the Veteran's contentions of tinnitus both during and since his active military service. However, the current recollections of persistent or recurrent tinnitus since service is not deemed credible when viewed against the entire evidentiary record. In addition to the lack of tinnitus reports in service (which is a factor for consideration), the Veteran specifically denied tinnitus during a July 15, 1976 VA evaluation. This is the first statement on the matter. Overall, the Board places significant probative weight to the July 15, 1976 statement as it was made while the events were fresh in his memory, and bears the indicia of reliability as it was made in the context of seeking appropriate medical treatment. See Lilly's An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). See generally Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). On the other hand, the current recollections of the Veteran and his spouse directly contradict the July 15, 1967 statement which tends to impeach the current reliability and credibility of such statement. In addition, the recollections are made several decades after the events in question and are not consistent with the entire evidentiary record. For these reasons, the Board places greater probative weight to the Veteran's denial of tinnitus symptoms in 1976 than the current recollections made many decades later in the context of seeking compensation benefits. Additionally, the opinions of the Veteran and his spouse, as well as the evidentiary value of the articles, are greatly outweighed by the opinion of the November 2010 VA audiologist who has more expertise and training than the Veteran and his spouse to speak to the specific medical issues at hand. For the reasons set forth above, the Board finds that the lay statements, asserting that the Veteran's tinnitus has been present since his active military service, are not credible. Therefore, these statements do not warrant a grant of service connection or a determination that further development of the medical evidence is required. All other evidence of record, aside from the Veteran's statements in support of this current claim, is unfavorable to the claim for service connection for tinnitus. The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert, 1 Vet. App. at 49. The Veteran's claim of entitlement to service connection for tinnitus is not warranted. (CONTINUED ON THE NEXT PAGE) ORDER The appeal pertaining to the claim of entitlement to service connection for PTSD is dismissed. Service connection for an acquired psychiatric disorder, to include depression and anxiety, but not including psychosis, personality disorder, schizophrenia, and alcohol abuse, is granted, subject to the legal criteria governing the payment of monetary benefits. Service connection for sensorineural hearing loss of the right ear is granted, subject to the legal criteria governing the payment of monetary benefits. Service connection for sensorineural hearing loss of the left ear is denied. Service connection for tinnitus is denied. REMAND Inasmuch as the Board regrets the additional delay of this appeal, a remand is required before the gastrointestinal disorder claim can be properly adjudicated. Throughout his appeal, the Veteran has argued that his gastrointestinal disorder is attributable to his psychiatric symptoms. As the Veteran's acquired psychiatric disorder has been awarded service connection in this decision, the Board must now address secondary service connection for the Veteran's gastrointestinal disorder claim. 38 C.F.R. § 3.310 (2012). In this regard, the Veteran has not been provided with a proper duty-to-assist notice letter. Specifically, the Veteran has not been informed of the requirements for establishing secondary service connection. The Veteran must be provided with this requisite notice. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. Additionally, in the case of a disability compensation claim, VA's duty to assist includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Here, a current gastrointestinal disorder diagnosis was provided at the Veteran's recent November 2010 VA examination. Additionally, the Veteran is currently service-connected for an acquired psychiatric disorder. The claims file contains private medical opinions, which suggest a relationship between the service-connected acquired psychiatric disorder and the gastrointestinal disorder; however, no conclusive opinions are of record. The November 2010 VA examiner did not provide a medical opinion on the issue of secondary service connection. 38 C.F.R. § 3.310. Thus, the Board finds that this medical opinion is necessary before the claim can be decided on the merits. Therefore, upon remand, the Board finds that the AMC must provide the Veteran a VA medical opinion addressing this issue. See 38 C.F.R. § 3.159(c)(4). Finally, the most recent outpatient treatment records from the VA South Texas Health Care System are dated from March 2012, as shown on the Veteran's Virtual VA claims file. On remand, all pertinent VA treatment records since this date should be obtained and added to the claims file. All private medical records contained in the claims file should also be updated. See 38 U.S.C.A. § 5103A(a)(1), (b)(1), (c)(1); Loving v. Nicholson, 19 Vet. App. 96, 101-03 (2005). Accordingly, the case is REMANDED for the following actions: 1. Send the Veteran another VCAA letter pertaining to his gastrointestinal disorder claim, to include information regarding establishing secondary service connection under 38 C.F.R. § 3.310. 2. Obtain all pertinent VA outpatient treatment records from the VA South Texas Health Care System since March 2012 that have not been secured for inclusion in the record. Ensure that the Veteran has not been recently treated by any other local VAMCs. If no additional medical records are located, a written statement to that effect should be requested for incorporation into the record. 3. Update all private treatment records currently contained in the claims file. If no additional medical records are located, a written statement to that effect should be requested for incorporation into the record. 4. After completing the above actions, the RO/AMC shall ask the original November 2010 VA examiner to provide an addendum opinion, or if the VA examiner determines that it is necessary, schedule the Veteran for a VA examination with an appropriate expert to determine the etiology of his currently diagnosed gastrointestinal disorder. The VA examiner should thoroughly review the Veteran's VA claims file, to include his STRs, as well as a complete copy of this Remand in conjunction with the examination. The VA examiner should note that this action has been accomplished in the VA examination report. The VA examiner is requested to specifically address the following: Is it at least as likely as not that the Veteran's currently diagnosed gastrointestinal disorder, including duodenitis, irritable bowel syndrome, and/or diverticulitis, is due to or aggravated beyond the normal progress of the disorder by his service-connected acquired psychiatric disorder? The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., diagnosis, etiology) as it is to find against the conclusion. In forming his or her opinion, the VA examiner is asked to consider the Veteran's lay statements regarding the progression of the disorder, and comment on whether the Veteran's statements make sense from a medical point of view. Additionally, the VA examiner should give consideration of the assessments of record that the incident of bowel defecation on the floor in service could be a manifestation of irritable bowel syndrome (IBS), that his IBS is associated with tension, and that his GI symptoms are exacerbated by his psychiatric disorder. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering this determination, the VA examiner should specifically cite each reference material utilized. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The VA examination report prepared must be typed. The Veteran is hereby notified that it is his responsibility to report for this and all examinations scheduled in connection with this REMAND at whatever location it is scheduled, and to cooperate in the development of his case. The consequences of failure to report for a VA examination may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 5. After the above actions have been completed, readjudicate the Veteran's gastrointestinal disorder claim. If the claim remains denied, issue to the Veteran and his representative a Supplemental Statement of the Case (SSOC). Afford them the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs