Citation Nr: 1313519 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 04-32 017 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), paranoid personality disorder, and depression with chronic adjustment disorder, and to include as secondary to the service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1969 to February 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2003 rating decision by the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota, which denied the Veteran's claims of service connection for PTSD and depression with chronic adjustment disorder. The Veteran filed a Notice of Disagreement (NOD) with respect to the decision later that month. A Statement of the Case (SOC) was issued in May 2004 and the Veteran perfected his appeal in July 2004. Thus, the Veteran has timely appealed this issue. The Veteran testified at a Decision Review Officer (DRO) hearing at the RO in October 2003. The transcript of the hearing is associated with the claims file and has been reviewed. In its February 2008 remand, the Board recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, based on recent case law. In February 2008, July 2009, and October 2011, the Board remanded this issue to RO via the Appeals Management Center (AMC), in Washington, DC, for further development. The case has now been returned to the Board for appellate disposition. The Veteran's Virtual VA paperless claims file has also been reviewed in preparing this remand, as well as the Veteran's paper claims file. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disorder was not manifested during his active military service, is not shown to be causally or etiologically related to his active military service, is not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from the military, and is not shown to be caused or aggravated by a service-connected disability. 2. The Veteran was not in combat and does not have a diagnosis of PTSD based upon a verified in-service stressor. 3. The Veteran's current PTSD diagnosis is not shown to be caused or aggravated by a service-connected disability. 4. The Veteran's paranoid personality disorder is a congenital or developmental defect, which is not a disease or injury for the purposes of service connection. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder was not incurred in or aggravated by the Veteran's active military service, to include as due to a service-connected disability, nor may a psychosis be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1132, 1137, 1153, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309, 3.310 (2012). 2. PTSD was not incurred in or aggravated by the Veteran's active military service, to include as due to a service-connected disability. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304(f), 3.310 (2012). 3. The Veteran has no legal entitlement to service connection for a personality disorder. 38 C.F.R. § 3.303 (2012). 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) (noting that 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 claim. 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) (finding that the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). I. VA's Duties to Notify and Assist Under applicable law, 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 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) (West 2002); 38 C.F.R. § 3.159(b) (2012); 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. 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). 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) (West 2002); 38 C.F.R. § 3.159(b) (2012). Letters from the RO dated in October 2002, March 2008, and August 2009 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, 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 March 2008 letter addressed the requirements for establishing secondary service connection, and also provided the Veteran with information concerning the evaluation and effective date that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The March 2008 and August 2009 duty-to-assist letters were not provided before the initial RO adjudication of his claim in June 2003. However, after the Veteran was provided the letters, the claim was then readjudicated in the May 2011 and July 2012 Supplemental Statement of the Cases (SSOCs) based on any additional evidence received in response to those additional notice letters. This is important to point out because if there was no VCAA notice provided prior to the initial adjudication of the claim, or for whatever reason the notice provided was inadequate or incomplete, this timing error may be effectively "cured" by providing any necessary notice and then going back and readjudicating the claim, including in a Statement of the Case (SOC) or SSOC, such that the intended purpose of the notice is not frustrated and the Veteran is given ample opportunity to participate effectively in the adjudication of his claim. In other words, this timing error in the provision of the notice is ultimately inconsequential and, therefore, at most nonprejudicial, i.e., harmless error. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). 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 claim. 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 (West 2002); 38 C.F.R. § 3.159 (2012). Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. His STRs, personnel records, Social Security Administration (SSA) disability benefits records, and post-service VA and private treatment records have been obtained. The RO made attempts to obtain the Veteran's private treatment records from the Methodist Medical Center, but the Methodist Medical Center submitted a statement indicating that they did not have any records for the Veteran. Accordingly, 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 was afforded VA examinations and medical opinions in November 2008, August 2009, October 2009, February 2010, April 2010, June 2010, November 2010, April 2011, and November 2011. The examination reports have been included in the claims file for review. The examinations and medical opinions involved reviews of the claims file, thorough examinations of the Veteran, and opinions that were supported by sufficient rationale. Therefore, the Board finds that the VA examinations and medical opinions are 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 claim. The Board is also satisfied as to substantial compliance with its February 2008, July 2009, and October 2011 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 VA examinations and medical opinions, which were obtained in November 2008, August 2009, October 2009, February 2010, April 2010, June 2010, November 2010, April 2011, and November 2011. The remand also included sending the Veteran additional VCAA notice regarding the requirements for establishing secondary service connection. The Veteran was provided this notice letter in March 2008. Finally, the remand included readjudicating the Veteran's claim, which was accomplished in the January 2009, May 2011, and July 2012 SSOCs. 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 claim. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Service Connection A. General Regulations and Statutes The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD, and to include as secondary to his service-connected disabilities. To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) medical evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110. 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); 38 C.F.R. § 3.303(d). Service connection for PTSD, in particular, requires medical evidence diagnosing the disorder in accordance with 38 C.F.R. § 4.125(a) (2012); a link, established by medical evidence, between current symptoms and an in-service stressor; and, credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) and 38 C.F.R. § 4.125 (requiring PTSD diagnoses to conform to the criteria in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (DSM-IV)). The evidence necessary to establish the occurrence of a stressor during the military service to support a claim for PTSD will vary depending on whether the veteran was "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60, 66 (1993). If the evidence establishes that the veteran was engaged in combat with the enemy or was a prisoner of war (POW), and the claimed stressor is related to combat or POW experiences (in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressors are consistent with the circumstances, conditions, or hardships of the veteran's service), the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. Where the claimed stressor is not related to combat, however, a veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must contain service records or other corroborative evidence that substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Cohen v. Brown, 10 Vet. App. 128, 142 (1997). Such corroborating evidence cannot consist solely of after-the-fact medical nexus evidence. See Moreau, 9 Vet. App. at 396. However, during the pendency of this appeal, on July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. 75 Fed. Reg. 39843 (July 13, 2010). This revision adds to the types of PTSD claims that VA will accept through credible lay testimony alone as being sufficient to establish occurrence of an in-service stressor without undertaking other development to verify the veteran's account. The primary effect of the amendment of 38 C.F.R. § 3.304(f) is the elimination of the requirement for corroborating evidence of a claimed in-service stressor if it is related to the veteran's "fear of hostile military or terrorist activity." In place of corroborating reported stressors, a medical opinion must instead be obtained from a VA, or VA contracted, psychiatrist or psychologist. Certain diseases, chronic in nature, may be presumed to have been incurred during the active military service, if the evidence shows that the disease became manifest to a degree of 10 percent or more within one year from separation from active duty, even though there is no evidence of the disease during the active military service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). Psychoses (but not PTSD) have been identified as a chronic disease subject to presumptive service connection under 38 C.F.R. § 3.309(a). Id. Regarding the acquired psychiatric disorder (not including PTSD), the Board observes that 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. 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). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. Id. The Board notes that 38 C.F.R. § 3.310 was amended, effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a non-service-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a non-service-connected disorder, consideration is required as to what the competent evidence establishes as the baseline level of severity of the non-service-connected disease or injury (prior to the onset of aggravation by service-connected disability), in comparison to the medical evidence establishing the current level of severity of the non-service-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular non-service-connected disorder. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). It appears as though the new regulatory amendment poses a new restriction on claimants. Nonetheless, because the Veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the revision, as this version is more favorable to the Veteran. See generally VAOGCPREC 7-03 and VAOPGCPREC 3-00. After the evidence has been assembled, the Board is responsible for evaluating the entire record. 38 U.S.C.A. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Indeed, in Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. B. Presumption of Soundness Initially, the Board will begin by addressing whether the Veteran's acquired psychiatric disorder, to include PTSD, pre-existed his active military service. Specifically, in a September 2005 statement in support of his claim, the Veteran contended that his depression began prior to service and was aggravated by his service in the Republic of Vietnam. A November 2009 VA outpatient treatment record documented a history of depressive disorder and PTSD since the Veteran's childhood. The February 2010 VA examiner also found that there was evidence that the Veteran's depression existed prior to service. In this regard, every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Until rather recently, the provisions of 38 C.F.R. § 3.304(b) only required a finding that clear and unmistakable evidence (CUE) showed that an injury or a disease existed prior to service in order to rebut this presumption of soundness. However, the provisions of 38 C.F.R. § 3.304(b) were invalidated as being inconsistent with 38 U.S.C.A. § 1111. See generally Cotant v. Principi, 17 Vet. App. 116 (2003); Jordan v. Principi, 17 Vet. App. 261 (2003); see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Pursuant to these developments, to now rebut the presumption of soundness at service entry, there must be CUE showing the disorder preexisted service and CUE that the disorder was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 (July 16, 2003). CUE is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence."). It is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the non-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003), citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). Here, there is no documentation of an acquired psychiatric disorder, to include PTSD, or its associated symptoms, on the Veteran's March 1969 military entrance examination. Therefore, it is presumed the Veteran did not have an acquired psychiatric disorder, to include PTSD, when he entered the active military service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Consequently, the standards announced in VAOGPREC 3-2003 are applicable, i.e., the two-pronged rebuttal standard requiring CUE of both pre-existence and of no in-service aggravation; however, based on the evidence described above, these standards have not been met. Therefore, the Veteran is afforded the presumption of soundness (i.e., he is presumed sound and without any psychiatric disorders at the time of his entry into the military). 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The Board will now proceed to address his claims on the merits. C. Acquired Psychiatric Disorder (Not Including PTSD) The Veteran seeks service connection for an acquired psychiatric disorder, not including PTSD, to include as secondary to his service-connected disabilities. The Board will begin by addressing direct service connection. As noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current diagnosis has been established. At a July 2003 VA outpatient treatment visit, the Veteran was diagnosed with dysthymic disorder. On VA examination in January 2008, the Veteran was diagnosed with depression. On VA examination in November 2010, the Veteran was diagnosed with depressive disorder, not otherwise specified. 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 STRs are silent for documentation of an acquired psychiatric disorder. The records reveal no complaints or treatment related to the Veteran's acquired psychiatric disorder. At his December 1970 military separation examination, an acquired psychiatric disorder was not noted. Thus, the second element of direct service connection has not been satisfied. Post-service, the Veteran was first treated for his acquired psychiatric disorder in August 1999 by the VA Home Admission. Specifically, the Veteran was diagnosed with "possible depression" following a physical examination. The Veteran was then formally diagnosed with adjustment disorder and depressive disorder by the VA Medical Center (VAMC) in February 2001. The Veteran left the active military service in 1971 and did not complain of psychiatric symptoms until over twenty-five years later. This intervening lapse of so many years between his separation from military service and the first documented manifestation of this claimed disorder is probative evidence against his claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disorder). 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, a VA psychiatric examination was conducted in November 2008. The VA examiner reviewed the claims file, administered tests, and conducted an interview with the Veteran. After a detailed description of the evaluation, the examiner diagnosed the Veteran with depression, not otherwise specified. He opined that none of the Veteran's psychopathology was related to his time in the military. The Veteran was afforded another VA examination in August 2009. Following a physical examination of the Veteran and a review of the claims file, the VA examiner found that the Veteran's current acquired psychiatric disorder was not caused by or a result of his military service. The examiner reasoned that the Veteran's acquired psychiatric disorder was diagnosed after his military discharge. A VA addendum medical opinion on the acquired psychiatric disorder issue was obtained in October 2009, but the VA examiner did not provide a medical opinion on the issue of direct service connection. A VA addendum medical opinion on the acquired psychiatric disorder issue was obtained in February 2010. The VA examiner found that there was an absence of clear and unmistakable evidence that the Veteran's current acquired psychiatric disorder was aggravated by his active military service. The examiner based his opinion on a review of the Veteran's claims file. Another VA addendum medical opinion was obtained in April 2010. The VA examiner found that none of the Veteran's forms of psychopathology were related to his time in the military. The examiner determined that the Veteran's current mental disorders were not due to or aggravated by his time in the military. The examiner noted that changes in the mental disorder can occur, but these were not due to the service-related activity. The examiner based his opinion on a review of the Veteran's claims file. In June 2010, the VA examiner added that the facts of the case had not changed. He stated that a disorder could worsen during the military but not be the direct result of the Veteran's time in the military. No further information was provided. The Veteran was afforded another VA psychiatric examination in November 2010, but the VA examiner did not provide a medical opinion. The examiner merely described the Veteran's current symptoms. A VA addendum medical opinion was rendered in April 2011 by the November 2010 VA examiner. The VA examiner reviewed the Veteran's claims file, and found that at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. Thus, the examiner judged the Veteran to be a non-reliable historian. As a result of this finding, and following a review of the Veteran's claims file, the examiner determined that it was impossible to offer any reliable/credible opinion without resort to mere speculation. Another VA addendum medical opinion from the November 2010 VA examiner was obtained in November 2011. In the opinion, the examiner added that at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. The examiner stated these symptoms made it difficult to determine the presence or absence of any symptoms associated with PTSD or any other psychiatric disorder. Thus, the examiner was unable to provide a medical opinion. The Board notes that the Court held in Jones v. Shinseki, 23 Vet. App. 382, 389-91 (2010), that when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; instead, a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90. The Jones Court further held that, "while VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence. Notwithstanding the duty to assist, it remains the claimant's responsibility to submit evidence to support his claim." Id. at 391. Here, the Board finds that the November 2010 VA examiner adequately explained the reasons for his inability to render a nexus opinion, and accordingly the Board does not find the medical opinion to be inadequate. The examiner reviewed the Veteran's entire claims file prior to providing his medical opinion. The examiner also found that the Veteran was an unreliable historian, following a physical examination of the Veteran. Therefore, the Board does not find that the VA examiner was using speculation as a "substitute" when he provided his medical opinion, and provided a thorough rationale. The Board finds that the VA examiner considered all pertinent and available medical facts in forming his medical opinion. The examiner adequately explained the reasons for his inability to render a nexus opinion in the April 2011 and November 2011 addendum medical opinions. Thus, the VA examiner provided a "legitimate inconclusive opinion," and VA does not have to demand a conclusive opinion from the examiner. Id. at 391 (stating that "[w]hile VA has a duty to assist the veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence."). The Board notes that service connection may not be based on a resort to pure speculation or even remote possibility. See 38 C.F.R.§ 3.102. In summary, the Board finds that the aforementioned VA examiners reviewed the STRs and other evidence in the Veteran's claims folder. The examiners 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. The Veteran and his representative have been accorded ample opportunity to present competent medical evidence in support of his claim; they have failed to do so. See 38 U.S.C.A. § 5107(a) (it is the claimant's responsibility to support a claim for VA benefits). For all of these reasons, service connection on a direct basis is not warranted. The Board will now address secondary service connection. As noted above, the first element of secondary service connection requires evidence of a current disorder, and this element has been satisfied. As stated above, the second element of secondary service connection requires evidence of a service-connected disability. Here, the Veteran is currently service-connected for left second toe disability, left foot and ankle disabilities, a lumbar spine disability, a left hip disability, nerve damage of the lower extremity, bilateral foot fungus, and tinnitus. Thus, the Veteran has satisfied the second element of secondary service connection. As previously mentioned, the third element of secondary service connection requires medical nexus evidence establishing a connection between the service-connected disability and the current disorder. In this regard, a July 2005 VA treatment record reflected that the Veteran was diagnosed with depressive disorder, not otherwise specified, on Axis I by a VA psychiatrist (Dr. W.M.K.). Dr. W.M.K. specifically wrote that the Veteran had "a number of physical disabilities which have no doubt impacted his mental health." The physician did not provide further rationale or review the Veteran's claims file prior to providing the opinion. Accordingly, based on this statement, the Board remanded the claim for a VA examination to be obtained to address the etiology of the Veteran's acquired psychiatric disorder. The Veteran was seen for VA psychiatric examinations in November 2008 and August 2009, but the VA examiners did not address secondary service connection in their medical opinions. A VA addendum medical opinion on the acquired psychiatric disorder issue was obtained in October 2009. The VA examiner determined that the Veteran's existing psychiatric disorder was less likely than not caused or aggravated by his service-connected disabilities. The examiner based his opinion on a review of the Veteran's claims file. VA addendum medical opinions were obtained in February 2010, April 2010, and June 2010, but these opinions did not address secondary service connection. The Veteran was afforded another VA psychiatric examination in November 2010, but the VA examiner did not provide a medical opinion. The examiner merely described the Veteran's current symptoms. The Veteran was afforded a VA addendum medical opinion in April 2011 by the November 2010 VA examiner. The VA examiner reviewed the Veteran's claims file, and found that, at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. Thus, the examiner judged the Veteran to be a non-reliable historian. As a result, and following a review of the Veteran's claims file, the examiner determined that it was impossible to offer any reliable/credible opinion without resort to mere speculation. Another VA addendum medical opinion from the November 2010 VA examiner was obtained in November 2011. In the opinion, the examiner added that, at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. The examiner stated these symptoms make it difficult to determine the presence or absence of any symptoms associated with PTSD or any other psychiatric disorder. Thus, the examiner was unable to provide a medical opinion. As noted above, in Jones, 23 Vet. App. at 389-91, the Court held that when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; instead, a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90. The Jones Court further held that, "while VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence. Notwithstanding the duty to assist, it remains the claimant's responsibility to submit evidence to support his claim." Id. at 391. Here, the Board finds that the November 2010 VA examiner adequately explained the reasons for his inability to render a nexus opinion, and accordingly the Board does not find the medical opinion to be inadequate. The examiner reviewed the Veteran's entire claims file prior to providing his medical opinion. The examiner also found that the Veteran was an unreliable historian, following a physical examination of the Veteran. Therefore, the Board does not find that the VA examiner was using speculation as a "substitute" when he provided his medical opinion, and provided a thorough rationale. The Board finds that the VA examiner considered all pertinent and available medical facts in forming his medical opinion. The examiner adequately explained the reasons for his inability to render a nexus opinion in the April 2011 and November 2011 addendum medical opinions. Thus, the VA examiner provided a "legitimate inconclusive opinion," and VA does not have to demand a conclusive opinion from the examiner. Id. at 391 (noting that "[w]hile VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence."). The Board finds the negative evidence outweighs the positive on the issue of secondary service connection. It is to be noted that the Board is not free to substitute its own judgment for as such a medical expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). However, the Board is required to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). With regard to the July 2005 private statement, the physician did not review the Veteran's claims file prior to providing his medical opinion, and did not provide any rationale for his medical opinion. The physician also did not state which specific service-connected disabilities were impacting the Veteran's mental health and how these service-connected disabilities were impacting the Veteran's mental health. Thus, the Board finds that the July 2005 statement cannot be considered as competent medical evidence of an etiological relationship between the Veteran's current service-connected disabilities and his current acquired psychiatric disorder. In contrast, the aforementioned VA examiners clearly reviewed the STRs and other evidence in the Veteran's claims folder. The VA examiners provided negative nexus medical opinions that are supported by and consistent with the evidence of record. The examination reports of the Veteran's medical history and his clinical findings are consistent with the entire body of medical evidence of record. There is no basis on which to find that the reports are incomplete or insufficient in any way. The VA and private treatment records do not provide contrary evidence to that obtained at the VA examinations. As such, service connection on a secondary basis is also not warranted. Additionally, the Board notes that the Veteran reports continuous symptomatology since his active military service. However, the Veteran's contentions are not supported by the medical evidence of record. As stated above, the earliest pertinent post-service medical evidence associated with the claims file is dated from 1999, over twenty-five years after the Veteran's military separation in 1971. Further, the STRs do not show that the Veteran developed a chronic psychosis during his active military service. The STRs do not document any complaints of or treatment for psychiatric symptoms. The Veteran's December 1970 military separation examination did not document an acquired psychiatric disorder. Thus, the Board finds that the medical evidence does not establish a "chronic disorder." 38 C.F.R. § 3.303. The Veteran's service connection claim cannot be granted on this theory of entitlement. The Board also finds that the Veteran is not entitled to presumptive service connection for psychoses. As stated above, the earliest pertinent post-service medical treatment records are dated from 1999, and the Veteran was separated from the active duty in 1971. No diagnosis of psychoses 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 arguments in support of his claim. The Veteran contends that his acquired psychiatric disorder is directly related to his active military service, or, in the alternative, is related to his service-connected disabilities. Regarding direct service connection, the Board acknowledges that the Veteran is competent, even as a layperson, to attest to factual matters of which he has first-hand knowledge, e.g., an injury during his active military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered, and that competent lay evidence can be sufficient in and of itself. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), and in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a disorder when: (1) a layperson is competent to identify the medical disorder (noting that sometimes the layperson will be competent to identify the disorder where the disorder is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Id. Although the Veteran is competent to report that his psychiatric symptoms began during his military service and have continued since that time, resulting in his current acquired psychiatric disorder, the Board must still weigh his lay statements against the medical evidence of record. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In making this credibility determination, the Board does not find the Veteran's statements concerning the etiology of his acquired psychiatric disorder to be credible, since his STRs make no reference to any psychiatric symptoms, and the first indication in the record of psychiatric symptoms is in 1999, more than twenty-five years after his separation from the active duty. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996); see also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). It is important to point out that the Board does not find that the Veteran's 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 (finding that "the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Rather, the Veteran's statements are found to be incredible because they are inconsistent with the evidence of record, which fails to show an in-service incurrence of his acquired psychiatric disorder and a diagnosis of an acquired psychiatric disorder until over twenty-five years after his military discharge, and due to the negative medical nexus opinions of record. For the reasons set forth above, the Board finds that the Veteran's lay statements that his symptoms have 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 an acquired psychiatric disorder. Regarding secondary service connection, the Board notes that although laypersons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, secondary service connection, this issue falls outside the realm of common knowledge of a layperson. See Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007) (laypersons not competent to diagnose cancer). As a layperson, it is not shown that he possesses the medical expertise to provide such an opinion. No competent medical opinions linking his acquired psychiatric disorder to his service-connected disabilities have been presented. The VA examiners considered the Veteran's lay assertions in forming their negative nexus medical opinions, but ultimately found that the Veteran's current acquired psychiatric disorder was not related to his service-connected disabilities. Thus, as previously stated, the medical evidence of record is only against the Veteran's claim. 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 an acquired psychiatric disorder, not including PTSD, to include as secondary to his service-connected disabilities, is not warranted. D. PTSD The Veteran seeks service connection for PTSD, to include as secondary to his service-connected disabilities. The Board will begin by addressing direct service connection. As noted above, the first element of service connection requires medical evidence of a current disorder. Here, a current DSM-IV diagnosis of PTSD has been established. In February 2010, the Veteran was diagnosed with PTSD, under the DSM-IV criteria, by his VA treating licensed social worker. The first element of 38 C.F.R. § 3.304(f), medical evidence diagnosing PTSD, has therefore been met. With regard to the question of whether the Veteran served in combat with the enemy, the Board has considered his military personnel and medical records and the Veteran's own statements. The Veteran's DD-214 Form reflects that he served on active duty with the Army in Europe (USAREUR) from March 1969 to February 1971, and that he received no combat citations. His DD-214, his STRs, and his personnel records do not document service in the Republic of Vietnam (Vietnam) during his active military service. His STRs reveal no combat wounds. His Military Occupational Specialty (MOS) was Field Wireman. Thus, the evidence of record does not establish that the Veteran was engaged in combat in connection with his MOS. The Board therefore finds that, based on all the evidence, the Veteran did not engage in combat during his active duty. Since the Veteran did not engage in combat with the enemy, his lay testimony alone is not enough to establish the occurrence of an alleged stressor. Mere allegations are insufficient to establish service stressors for PTSD; instead, official service records or other credible supporting evidence must corroborate stressors. See Cohen, 10 Vet. App. at 138-50; Zarycki, 6 Vet. App. at 98; 38 C.F.R. § 3.304(f). Regarding his stressor, the Board observes that in a statement dated in December 2002, the Veteran described witnessing a fellow recruit blow himself and two others up with a grenade during his basic training from March 1969 to February 1971. The Veteran also reported falling 60 feet from a pole during his training, which caused him some bruises. He also recalled watching two other soldiers fall from the pole and have to be taken to the hospital. The Veteran also stated that he had active duty service in Vietnam from the fall of 1970 until his discharge in 1971. During his tour in Vietnam, the Veteran indicated that he was stationed in the transit unit in Cammaron Bay and often found himself under mortar attacks. After the attacks, the Veteran reported seeing casualties (soldiers, women, and children) lying on the ground. In a statement dated in September 2005, the Veteran reiterated these stressors. The Board is unable to concede the Veteran's PTSD stressors. The Veteran's service and personnel records do not demonstrate that he served in Vietnam; instead, the records document that he served in the United States and Europe. Furthermore, at his November 2010 VA examination, the Veteran told the examiner that he was stationed in Europe during his active military service, and not Vietnam as he had previously reported. The November 2010 VA examiner, in the November 2010 examination report and in addendum medical opinions dated in April 2011 and November 2011, found the Veteran to be a "non-reliable historian," due to a "markedly impaired memory," "severely impaired attention and concentration skills," and "clouded judgment." The Veteran's STRs are silent for documentation of PTSD or psychiatric symptoms. The records reveal no complaints or treatment related to the Veteran's PTSD. At his December 1970 military separation examination, PTSD or its associated symptoms were not noted. The only evidence the Veteran has submitted to support his claimed stressors are his own statements. This is not sufficient where combat service is not documented and he has not provided sufficient detail to permit the VA to verify his claimed stressors. See 38 U.S.C.A. § 1154; 38 C.F.R. § 3.304(f). Furthermore, in October 2002, the RO sent the Veteran a letter requesting the specific details and dates of his PTSD stressors. The RO then submitted the information described above regarding the Veteran's basic training stressors to the Center for Unit Records Research (CURR) in February 2004 and April 2004, but CURR was unable to confirm the stressors because the date ranges were too large. The Veteran was notified of this in his May 2004 SOC and afforded the opportunity to submit the names of the soldiers and smaller date ranges, but the Veteran did not provide this information. The duty to assist is "not a one way street," and the RO can only proceed so far without help from the Veteran himself. Warmhoff v. Brown, 8 Vet. App. 517, 522 (1996). Where the evidence fails to support any verifiable in-service stressor, service connection for PTSD must be denied. Under the circumstances described above, it is the Board's judgment that no reasonable possibility exists that further assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a)(2). The Veteran's PTSD stressors cannot be confirmed. Thus, the Veteran's claim fails under the old PTSD regulations. Additionally, under the new regulations, a VA psychiatrist or VA psychologist has not confirmed that (i) the claimed stressor is adequate to support a diagnosis of PTSD and (ii) the Veteran's symptoms are related to the claimed stressor. In February 2010, the Veteran was diagnosed with PTSD, under the DSM-IV criteria, by his VA treating licensed social worker, based on his claimed stressors. The social worker did not review the Veteran's claims file prior to providing her diagnosis. Mere acquiescence with the Veteran's contentions does not constitute competent medical evidence of diagnosis or causality. LeShore v. Brown, 8 Vet. App. 406 (1996). The Board is not bound to accept diagnoses and opinions by physicians who base a diagnosis of PTSD solely on the Veteran's unsupported statements. See Swann v. Brown, 5 Vet. App. 229 (1993). Nor is the Board bound to accept the Veteran's uncorroborated accounts of an in-service stressor or the opinions or diagnoses by physicians who rely on the Veteran's account of his stressful military service. Id. Furthermore, this VA social worker is not a VA psychologist or psychiatrist, as required under the new PTSD regulations. In contrast, when the Veteran was examined by VA psychologists at the November 2008 and November 2010 VA examinations, the VA examiners diagnosed the Veteran with depression and depressive disorder (Axis I of the DSM-IV) based on the Veteran's stressors, as described above and as reported at the examinations, based on a physical examination of the Veteran, and based on a review of the Veteran's claims file. The VA psychologists did not diagnose the Veteran with PTSD. In particular, the November 2008 VA examiner found that the Veteran did not meet the criteria for PTSD as he did not have an event in the combat zone which would qualify as a criterion A stressor under the DSM-IV. Similarly, the November 2010 VA examiner found that the Veteran's clouded consciousness, his severely impaired attention and concentration skills, and his markedly impaired memory functions, made it difficult to determine the presence or absence of any symptoms associated with PTSD. In a VA addendum opinion in April 2011, the November 2010 VA examiner added that the Veteran was a non-reliable historian. As a result, the examiner determined that it was impossible to offer any reliable/credible opinion without resort to mere speculation. Another VA addendum medical opinion from the November 2010 VA examiner was obtained in November 2011. In the opinion, the examiner added that at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. The examiner stated these symptoms made it difficult to determine the presence or absence of any symptoms associated with PTSD or any other psychiatric disorder. The remaining VA treatment records do not contain a DSM-IV diagnosis of PTSD by a VA psychologist or VA psychiatrist. Thus, there is no competent evidence that the Veteran has a current DSM-IV diagnosis of PTSD related to a verified stressor. The overall medical evidence fails to identify a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) and in accordance with the new regulations. Since the VA examiners (VA psychologists) have concluded that the Veteran does not have a current DSM-IV diagnosis of PTSD, they have not confirmed that the claimed stressors are adequate to support a PTSD diagnosis and this effectively ends the Board's application of the new regulation under 38 C.F.R. § 3.304(f)(3) in this case. Furthermore, evidence establishing the occurrence of an in-service stressor leading to PTSD is absent and there is no indication that the Veteran engaged in combat with the enemy during service, as would warrant the application of 38 U.S.C.A. § 1154. Under the circumstances, the Board finds that a preponderance of the evidence is against the claim for PTSD. The Veteran's claim for service connection for PTSD therefore fails on the basis that the preponderance of the evidence is against the claim that he has PTSD due to a verified stressor from his active military service. Under the circumstances here, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for PTSD, and thus the benefit of the doubt rule is inapplicable. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the service connection claim for PTSD must be denied on a direct basis. The Board will now address secondary service connection. As noted above, the first element of secondary service connection requires evidence of a current disorder, and this element has been satisfied. As stated above, the second element of secondary service connection requires evidence of a service-connected disability. Here, the Veteran is currently service-connected for left second toe disability, left foot and ankle disabilities, a lumbar spine disability, a left hip disability, nerve damage of the lower extremity, bilateral foot fungus, and tinnitus. Thus, the Veteran has satisfied the second element of secondary service connection. As previously mentioned, the third element of secondary service connection requires medical nexus evidence establishing a connection between the service-connected disability and the current disorder. Here, the only nexus opinions of record on the issue of secondary service connection are negative. Specifically, a July 2005 VA treatment record provided an opinion based on a diagnosis of depressive disorder, and thus it is not relevant to this discussion. The Veteran was seen for VA psychiatric examinations in November 2008 and August 2009, but the VA examiners did not address secondary service connection in his medical opinion. A VA addendum medical opinion on the acquired psychiatric disorder issue was obtained in October 2009. The VA examiner determined that the Veteran's existing psychiatric disorder was less likely than not caused or aggravated by his service-connected disabilities. The examiner based his opinion on a review of the Veteran's claims file. VA addendum medical opinions were obtained in February 2010, April 2010, and June 2010, but these opinions did not address secondary service connection. The Veteran was afforded another VA psychiatric examination in November 2010, but the VA examiner did not provide a medical opinion. The examiner merely described the Veteran's current symptoms. The Veteran was afforded a VA addendum medical opinion in April 2011 by the November 2010 VA examiner. The VA examiner reviewed the Veteran's claims file, and found that, at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. Thus, the examiner judged the Veteran to be a non-reliable historian. As a result, and following a review of the Veteran's claims file, the examiner determined that it was impossible to offer any reliable/credible opinion without resort to mere speculation. Another VA addendum medical opinion from the November 2010 VA examiner was obtained in November 2011. In the opinion, the examiner added that, at the November 2010 VA examination, the Veteran exhibited clouded consciousness, and severely impaired attention, concentration, and memory functions. The examiner stated these symptoms make it difficult to determine the presence or absence of any symptoms associated with PTSD or any other psychiatric disorder. Thus, the examiner was unable to provide a medical opinion. The Board reiterates the holding in Jones, 23 Vet. App. at 389-91, that when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; instead, a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90. The Jones Court further held that, "while VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence. Notwithstanding the duty to assist, it remains the claimant's responsibility to submit evidence to support his claim." Id. at 391. Here, the Board finds that the November 2010 VA examiner adequately explained the reasons for his inability to render a nexus opinion, and accordingly the Board does not find the medical opinion to be inadequate. The November 2010 examiner reviewed the Veteran's entire claims file prior to providing his medical opinion. The examiner also found that the Veteran was an unreliable historian, following a physical examination of the Veteran. Therefore, the Board does not find that the November 2010 VA examiner was using speculation as a "substitute" when he provided his medical opinion, and provided a thorough rationale. The Board finds that the VA examiner considered all pertinent and available medical facts in forming his medical opinion. The November 2010 examiner adequately explained the reasons for his inability to render a nexus opinion in the April 2011 and November 2011 addendum medical opinions. Thus, the November 2010 VA examiner rendered a "legitimate inconclusive opinion," and VA does not have to demand a conclusive opinion from the examiner. Id. at 391 (noting that "[w]hile VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence."). The Board notes that service connection may not be based on a resort to pure speculation or even remote possibility. See 38 C.F.R.§ 3.102. In summary, the Board finds that the aforementioned VA examiners clearly reviewed the STRs and other evidence in the Veteran's claims folder. The examiners 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. The Veteran and his representative have been accorded ample opportunity to present competent medical evidence in support of his claim; they have failed to do so. See 38 U.S.C.A. § 5107(a) (it is the claimant's responsibility to support a claim for VA benefits). For all of these reasons, service connection on a direct basis is not warranted. As such, service connection for PTSD on a secondary basis is also not warranted. In reaching this decision, the Board has considered the Veteran's arguments in support of his claim. The Veteran contends that his PTSD is directly related to his active military service, or, in the alternative, is related to his service-connected disabilities. Although laypersons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, as to the specific issues in this case, secondary service connection and whether the claimed stressor is adequate to support a diagnosis of PTSD, these issues fall outside the realm of common knowledge of a layperson. See Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007) (finding that laypersons not competent to diagnose cancer). As a layperson, it is not shown that he possesses the medical expertise to provide such opinions. The only medical opinions of record addressing these issues are negative. The VA examiners considered the Veteran's lay assertions in forming their medical opinions. Thus, as previously stated, the medical evidence of record is only against the Veteran's claim. 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 PTSD, to include as secondary to his service-connected disabilities, is not warranted. E. Personality Disorder The Board notes that throughout the appeal, the Veteran has also been diagnosed with paranoid personality disorder. See, e.g., VA treatment record dated in March 2009. There is no entitlement under the law to service-connect this disorder. By regulation, congenital or developmental defects such as personality disorders are not diseases or injuries for the purposes of service connection. 38 C.F.R. §§ 3.303(c), 4.9; see Winn v. Brown, 8 Vet. App. 510, 516 (1996); see also 38 C.F.R. § 4.130 (2012); American Psychiatric Association, DSM-IV. A claim for service connection for a personality disorder must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994); see also Beno v. Principi, 3 Vet. App. 439 (1992). The validity of the exclusion in 38 C.F.R. § 3.303(c) of congenital and development defects from the definition of disease or injury has been upheld. Winn, 8 Vet. App. at 510. The statutory provisions regarding reasonable doubt are not applicable to a determination based on preclusion by law. The Veteran's testimony as to personal observations are not applicable to a determination based on preclusion by law. The provisions of 38 U.S.C.A. § 5107(b) regarding reasonable doubt are not applicable to warrant a more favorable determination. The claim for service connection for a personality disorder must be denied. ORDER The claim for service connection for an acquired psychiatric disorder, to include PTSD, paranoid personality disorder, and depression with chronic adjustment disorder, and to include as secondary to the service-connected disabilities, is denied. ____________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs