Citation Nr: 1313852 Decision Date: 04/25/13 Archive Date: 05/03/13 DOCKET NO. 03-37 047 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1973 to September 1976. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a May 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. Jurisdiction of the Veteran's appeal is currently with the VA RO in Phoenix Arizona. The Veteran testified during a hearing at the Phoenix RO before the undersigned in February 2005. A transcript of that hearing is of record. This claim was previously before the Board in December 2005, April 2009, and June 2011. In a December 2005 decision, the Board reopened the Veteran's claim of entitlement to service connection for PTSD. At that time, the Board remanded the reopened claim, the Veteran's claims for service connection for diabetes mellitus and peripheral neuropathy, and the issue of whether new and material evidence had been received to reopen a claim for service connection for hypertension to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further development In an April 2009 decision, the Board granted the Veteran's claims for service connection for diabetes mellitus and peripheral neuropathy. At that time, the Board again remanded the issues of entitlement to service connection for a psychiatric disorder, including PTSD, and whether new and material evidence was received to reopen a claim for service connection for hypertension for further development to the RO via AMC for further development. In June 2011, the Board remanded the Veteran's claims for service connection for a psychiatric disorder, including PTSD, and hypertension to the RO via the AMC for further development. Then, in a September 2012 rating decision, the RO granted the Veteran's claim for service connection for hypertension. The RO's determination represents a full grant of the benefits sought as to the Veteran's claim. The Veteran was previously represented in this appeal by the Veterans of Foreign War (VFW). A March 2011 motion to withdraw from representation filed by VFW was granted by the undersigned that same month. Upon notice of VFW's withdrawal, the Veteran subsequently submitted a Pro Se Election Form, indicating that he wished to represent himself in his appeal. In the Introduction to its December 2005 Decision/Remand, the Board noted that, during his February 2005 Board hearing, the Veteran raised the issues of entitlement to service connection for neck, head, and left leg disorders, and bronchitis, and referred the matters to the Agency of Original Jurisdiction (AOJ) for appropriate action. There is no indication that the AOJ has yet considered these matters and they are, again, referred to the AOJ for appropriate development and adjudication. FINDING OF FACT The evidence preponderates against a finding that the Veteran currently has a psychiatric disorder, including PTSD, that had its onset during military service or is otherwise related to active duty. CONCLUSION OF LAW An acquired psychiatric disorder, to include PTSD, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 3.655 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b). This notice should be provided prior to an initial unfavorable decision on the claim by the AOJ. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA requires notice of what information and evidence not previously provided, if any, that is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran has received essential notice, had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). The RO sent VCAA letters to the Veteran in February 2002 and July 2004. Following the Board's December 2005 decision, an additional VCAA letter was provided to him in April 2006. This notice advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with the Court's holding in Dingess. As noted, any required VCAA notice should ideally be provided prior to an initial unfavorable decision on a claim by the AOJ. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then readjudicating the claim, such as in a statement of the case (SOC) or supplemental SOC (SSOC), so that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, after the issuance of the April 2006 notice that complied with the Dingess requirements, the Veteran's claim on appeal was readjudicated in a September 2008 SSOC, thereby curing any prior timing defect. Regarding the duty to assist, the RO obtained the Veteran's service treatment records (STRs) and personnel records, available VA and private treatment records, and records associated with his claim for disability benefits administered by the Social Security Administration (SSA). While the record suggests that the Veteran likely underwent more extensive private treatment by G.R.M., D.O., the Veteran did not respond to the RO/AMC's requests, most recently in August 2011, to provide signed release forms to allow VA to obtain a complete copy of his treatment records from that private clinician. Although the record indicates that the Veteran may have received treatment through VA medical facilities in Tomah, Milwaukee, and Madison, Wisconsin, requests for such records yielded negative responses from the facilities in August and September 2011, respectively. Consequently, in a December 2011 letter, the AMC notified the Veteran that records regarding his treatment were not found at these facilities and requested that he provide any records in his possession. The Veteran did not respond to this letter. Thus, the Board finds that VA satisfied its duty assist in this regard. The Veteran did not respond to the AMC's November 2012 letter requesting that he provide the specifics of his alleged stressful events in service. In a December 2012 memorandum, the RO concluded that there was insufficient information to verify his alleged stressful events in service. Further, efforts were repeatedly made to afford the Veteran thorough VA examinations to determine the nature and etiology of his claimed psychiatric disorder on appeal. He underwent a VA psychological examination in August 2008, the report of which is of record. The Board's April 2009 remand, in large measure, determined that the August 2008 VA examination was inadequate with respect to determining the etiology of diagnosed bipolar disorder and sought further medical comment. In May 2009, the Veteran failed to report for a VA examination scheduled in conjunction with his claim. He then canceled a VA examination scheduled in November 2009 in conjunction with his claim. A November 25, 2009 record indicates that he did not want to be rescheduled for another VA examination. According to a June 2012 RO memorandum, in June 2010, VA arranged for the Veteran to be evaluated at an outpatient clinic near his home. Two days before the scheduled examination, he called the RO and refused to be seen. A medical opinion was subsequently obtained from a new VA examiner in June 2010. However, that examiner determined that he could not provide an accurate opinion regarding the etiology of the Veteran's claimed psychiatric disorder without examining the Veteran in person. The June 2012 RO memorandum documents the Veteran absolute refusal to be seen for further VA examination. The Veteran did not make any attempt to show good cause or explain why he missed his last examination. While VA has a statutory duty to assist the Veteran in developing evidence pertinent to a claim, the Veteran also has a duty to assist and cooperate with the VA in developing evidence; the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190 (1991). VA's duty must be understood as a duty to assist the Veteran in developing his claim, rather than a duty on the part of VA to develop the entire claim with the Veteran performing a passive role. Turk v. Peake, 21 Vet. App. 565, 568 (2008). Therefore, remand for an additional VA examination is not warranted as to the claim for service connection for a psychiatric disorder, including PTSD. The Board has no legal recourse but to decide the Veteran's claim on basis of the existing record. 38 C.F.R. § 3.655. The Board further finds that the AMC substantially complied with the Board's June 2011 remand directives with respect to this claim. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In that remand, the Board directed that the AMC obtain the Veteran's treatment records from VA facilities in Battle Creek, and Lansing, Michigan, and Wisconsin; all outstanding treatment records from Dr. G.R.M.; and records associated with the Veteran's claim for SSA disability benefits. As noted, treatment records from VA medical facilities in Wisconsin were not located, and the Veteran did not respond to the AMC's August 2011 request for authorization to obtain his private treatment records from Dr. G.R.M. Records considered by the SSA in its award of disability benefits to the Veteran, and treatment records from the VA medical center in Battle Creek, Michigan, dated from February 2011 to December 2012, were received The Board finds that the RO/AMC substantially complied with the June 2011 remand directives such that no further action is necessary in this regard. Id. In Bryant v. Shinseki, 23 Vet App 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the February 2005 hearing, this Acting Veterans Law Judge outlined the issue on appeal and suggested that any evidence tending to show that pertinent disability was related to active duty or a service-connected disability would be helpful in establishing the claim. The undersigned and the Veteran's representative asked specific questions directed at identifying outstanding evidence that could substantiate his claim. He was requested to provide details about in-service stressful events and any post-service treatment in an effort to substantiate his service connection claim. Information provided at the hearing led to the Board's remand to obtain additional STRs and service personnel records (SPRs) and to afford him a VA examination. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. Accordingly, the Board finds that the duty to assist has been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating his current claim on appeal. II. Factual Background and Legal Analysis The Veteran has contended that he has an acquired psychiatric disorder, including PTSD due to military service. He maintains that he developed PTSD as a result of multiple alleged in-service stressors. Upon review of the pertinent evidence of record, and with consideration of the law and regulations applicable to the Veteran's case, the Board is of the opinion that the evidence preponderates against his claim for service connection for an acquired psychiatric disorder, including PTSD, and it must be denied. The Board notes that it has thoroughly reviewed the record in conjunction with this case. 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 appellant 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). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Under 38 U.S.C.A. §§ 1110 and 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Nevertheless, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To establish a right to compensation for a present disability, a veteran must show: "(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" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. Certain chronic diseases, such as psychoses, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). This is also a direct service connection theory of entitlement. Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). The Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a veteran for a long period of time or through a factually accurate medical history reported by a veteran. Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Considering first whether the Veteran currently has an acquired psychiatric disorder, the Board observes that the record reflects that the Veteran's was diagnosed with PTSD. A review of private treatment records from Dr. G.R.M., a family practitioner, shows that the Veteran was assessed with PTSD associated with Vietnam in October 1999. He was also noted to possibly have bipolar disorder at that time. Dr. G.R.M. provided signed statements in support of the Veteran's claim in July 2001 and May 2002, to the effect that he treated the Veteran since 1995, and the Veteran demonstrated severe problems with PTSD since that time. Dr. G.R.M. further indicated that the Veteran probably had "PTSD Vietnam symptoms." The August 2008 VA examination report includes a diagnosis of bipolar disorder. A PTSD diagnosis was not rendered at that time. According to the June 2010 VA examiner's opinion, based upon a review of the Veteran's medical records, the Veteran had PTSD based on childhood stressors. This diagnosis was made upon review of the record, as the Veteran refused to report for a VA examination. In December 2012, while hospitalized by VA, the Veteran had an Axis I diagnosis of a need to rule out Vietnam War PTSD. Thus, the record shows that the Veteran has been variously diagnosed with acquired psychiatric disorders including PTSD, a need to rule out Vietnam War PTSD, and bipolar disorder. A review of the Veteran's service treatment records fails to reveal any indication that he was treated for an acquired psychiatric disorder or any associated symptomatology during active military service. On a Report of Medical History completed in September 1976, prior to his discharge, the Veteran denied having frequent trouble sleeping, depression or excessive worry, memory loss, or nervous trouble of any sort. As noted, the first report of a psychiatric problem is from the mid-1990s, according treatment records and statements from Dr. G.R.M., the family practitioner, who indicated that the Veteran had PTSD and possibly a bipolar disorder. Prior to July 13, 2009, service connection for PTSD required that there be (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a)(2); a link, established by medical evidence, between current symptoms and an in-service stressor; (3) and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2009); see also Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The diagnosis of a mental disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and be supported by the findings of a medical examiner. See 38 C.F.R. § 4.125(a). Effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f) by liberalizing, in certain circumstances, the evidentiary standards for establishing the occurrence of an in-service stressor for non-combat Veterans. See 75 Fed. Reg. 39,843 -39,852 (effective July 13, 2010) (codified at 38 C.F.R. § 3.304(f)) (2011). Section 3.304 (f) was amended to include a new paragraph (f)(3) that reads as follows, in pertinent part: (f)(3) If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 75 Fed. Reg. 39843 -51 (July 13, 2010) and corrective notice at 75 Fed. Reg. 41092 (July 15, 2010). During the course of his appeal, the Veteran reported stressors associated with his service in the Republic of Vietnam. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the conditions or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the in-service stressor. 38 U.S.C.A. § 1154(b) (West 2002 and Supp. 2012). Where a current diagnosis of PTSD exists, the sufficiency of the claimed in-service stressor is presumed. Cohen v. Brown, 10 Vet. App. 128, 144 (1997). Nevertheless, credible evidence that the claimed in-service stressor actually occurred is also required. 38 C.F.R. § 3.304(f). See Anglin v. West, 11 Vet. App. 361, 367 (1998); Gaines v. West, 11 Vet. App. 353, 357 (1998), Cohen v. Brown, 10 Vet. App. at 138; Suozzi v. Brown, 10 Vet. App. 307 (1997). The Veteran has attributed the onset of his claimed acquired psychiatric disabilities to his active service. He has specifically attributed his PTSD diagnosis to several stressful in-service events. Specifically, he reported undergoing enemy fire from a sniper while launching a helicopter in Thailand. He also reported undergoing combat fire while flying in helicopters. During his February 2005 Board hearing, the Veteran testified that he was involved in the evacuation of Saigon in May 1975, while stationed in Thailand, and incurred enemy fire and saw multiple dead bodies of fellow soldiers. He testified to being involved in a couple of typhoons and believed he had chronic PTSD since his separation from service. The Veteran also reported several in-service stressors during his August 2008 VA examination. He indicated that serving on the flight line was, in itself, a frightening experience. The Veteran described an incident during which he fell out of a helicopter thirty feet above the ocean and had to be rescued. He was involved in numerous rescues, including during a typhoon, when he recovered live persons as well as dead bodies. The Veteran indicated that he was shot at while flying over South Vietnam and while on the ground. He also described experiencing hard landings after helicopter engines failed. He described being hazed after crossing the International Date Line. As noted, the Veteran failed to respond to the AMC's November 2012 letter requesting that he provide the specifics of his alleged stressful events in service. The December 2012 AMC memorandum concluded that there was insufficient information to corroborate a stressor associated with the Veteran's claim for service connection for PTSD. Even assuming, arguendo, that the Veteran's alleged stressors are verifiable or are consistent with the places, types, and circumstances of his service, the medical evidence of record fails to establish a link between his PTSD symptoms and his claimed in-service stressors. During the August 2008 VA PTSD examination, the examiner noted the Veteran's service in the United States Navy as a helicopter crewman and his reported in service stressors. The examiner indicated that he would describe the Veteran's level of stress exposure as low, based on the reported frequency and severity of the incidents. He noted that the Veteran's reported stressors included relatively minor stressful experiences as well as some experiences that might be expected to be reasonably stressful. The examiner further indicated that it was not clear that the Veteran's experiences reached a level where he was afraid for the loss of his life or limb. The VA examiner diagnosed the Veteran with bipolar disorder, in partial remission. In its April 2009 remand, the Board was specifically concerned with obtaining clarification from the August 2008 VA examiner as to whether the Veteran's bipolar disorder was at least as likely as not etiologically related to his active service. If the examiner was not available, this comment was requested to be provided by a new VA examiner. The Veteran was scheduled to appear for a new VA examination in May 2009, but failed to report, according to the August 2010 SSOC. In November 2009, he was scheduled for another VA examination. A few days before his scheduled examination, the Veteran notified the VA facility that he would not be able to make it to his appointment due to expected inclement weather. He further indicated that he did not wish to report for an examination as he was already examined, and believed all information should have been conveyed during the prior examination. The record reflects that a third effort was made to schedule the Veteran for a VA examination following the Board's June 2011 remand. The June 2012 RO memorandum indicates that a VA examiner determined that he could not provide an opinion regarding the Veteran's diagnosed psychiatric disorder without first conducting an examination. It was noted that, after contacting him by telephone, the Veteran absolutely refused to be seen for a new VA examination. The memorandum reflects that this also happened in June 2010. Thus, the June 2010 VA examiner proceeded to attempt to provide an opinion based on review of the claims folder. The June 2010 VA examiner noted that there was extensive evidence that the Veteran had a very traumatic childhood, and opined that it was at least as likely as not that the Veteran's physical abuse during childhood constituted evidence of traumatic stressors. The examiner indicated that there was evidence of recurrent problems with depression and anxiety but that, even giving the Veteran the benefit of the doubt, a PTSD diagnosis secondary to childhood stressors would be the more appropriate diagnosis. The examiner noted, however, that in order to make a more definitive diagnosis, he would need to examine the Veteran. With respect to the Veteran's military service, the VA examiner indicated that it would be mere speculation to make a diagnosis of PTSD secondary to Vietnam War experiences where the Veteran was unavailable to be examined. The examiner noted that, based on review of the record, there was no evidence of exposure to combat during his service, and there was no evidence that he had been awarded any medals indicative of combat. Following careful consideration of the above evidence, the Board concludes that the medical evidence of record fails to establish a link between the Veteran's PTSD and any in-service stressor(s). Moreover, none of the VA examiners confirmed that his claimed stressors were adequate to support a PTSD diagnosis or that his symptoms were related to his claimed stressors. Rather, the August 2008 VA examiner's opinion determined that there was insufficient evidence to clearly diagnose PTSD and the June 2010 VA examiner's opinion effectively determined that there was insufficient evidence to link the diagnosed PTSD to an in-service stressor. In reviewing the June 2010 VA examiner's opinion, the Board observes that an examiner's conclusion that a requested opinion is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion, and before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, it must be clear that the procurable and assembled data was fully considered and the examiner must explain the basis for such an opinion. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). But, here, the June 2010 VA examiner clearly noted that the deficiency with respect to being able to provide a definitive opinion was in the fact that the Veteran refused to be seen for a VA examination. Thus, the examiner indicated that he could not clearly determine whether there was a connection between the Veteran's PTSD and in-service stressor without interviewing the Veteran. Based on these facts, the Board finds that the June 2010 VA examiner's conclusion that he could not provide a definitive opinion as to whether the Veteran's PTSD was related to an in-service stressor is reliable. The only additional evidence pertaining to the Veteran's claimed PTSD is found in the written statements and private treatment records provided by Dr. G.R.M., the family practitioner, and in VA treatment records dated in December 2012 wherein the Veteran was noted to possibly have a PTSD diagnosis based on Vietnam War experiences. However, neither Dr. G.R.M. nor the VA physician in 2012 provided any indication as to a particular stressor that would support a PTSD diagnosis, and neither clinician clearly associated the Veteran's possible PTSD diagnosis with any claimed stressor(s). In short, they did not indicate why a PTSD diagnosis would be appropriate or which particular Vietnam experience(s) supported the PTSD diagnosis. Turning to the issue of whether service connection may be awarded for another psychiatric disorder, to include bipolar disorder, the Board notes that again, the evidence of record fails to establish that the Veteran suffered from an acquired psychiatric disorder during his service or that any such disability diagnosed after service had its onset after service or is related to an in-service disease, event, or injury. Notably, the August 2008 VA examiner, the only physician of record who clearly diagnosed a bipolar disorder, failed to provide an opinion as to the etiology of the disability. The Veteran refused to appear for a subsequent VA examination to enable the examiner, or another clinician, to render an opinion regarding the etiology of his psychiatric disorder. Thus, the June 2010 VA examiner was left to consider the evidence of record without the benefit of examining the Veteran and indicated only that the Veteran may possibly have bipolar disorder. Given the foregoing, there is also insufficient evidence of record to etiologically link any other acquired psychiatric disorder with the Veteran's service. Here, there is no evidence that the Veteran was diagnosed with a psychosis within one year of his separation from service in September 1976 and the record fails to show that a psychosis was manifested to a compensable degree within the one year following his active duty service discharge in September 1976, or that he has experienced a continuity of symptomatology indicative of a psychosis. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. As noted above, the Veteran failed to report for VA mental disorders examinations scheduled in May and November 2009, and refused to attend VA examinations in June 2010 and June 2012, in conjunction with his claim. Given the presumption of regularity of the mailing of VA examination scheduling notice and the fact that the Veteran has not contacted the RO with a reason for his failure to report, the Board finds that the Veteran failed to report to the scheduled May and November 2009 VA examinations without good cause. See 38 C.F.R. § 3.655. The Veteran reported having various alleged stressors associated with his military service in Vietnam, although there is no medical evidence reflecting treatment for a psychiatric disorder prior to mid-1990s, nearly 20 years after the Veteran's separation from active service in 1976. More significantly, the Veteran failed to report for VA mental disorders examinations scheduled in May and November 2009 and refused to be scheduled for VA examinations in June 2010 and June 2012, in conjunction with his claim. 38 C.F.R. § 3.655. There is not one competent medical opinion of record to support his service connection claim. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655. When a veteran fails without good cause to report for a VA examination requested by VA in conjunction with a claim, VA is not obliged to attempt to provide another. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a). VA offered the Veteran an opportunity to have four VA examinations to obtain a medical opinion regarding whether he had a psychiatric disorder incurred in or related to his military service. The Veteran, however, failed to appear for two scheduled VA examinations and refused to attend to two other offered examinations. His failure to cooperate in attending the examinations has left the record devoid of any competent opinion as to whether he has a psychiatric disorder that was incurred in or related to his active military service. 38 C.F.R. § 3.655(b). Given that there is no competent evidence that the claimed disorder is aggravated by a service-connected disorder, given that the Veteran failed to report for the scheduled examinations and, given that he has not provided good cause for his failure in this regard, his claim must be denied. The duty to assist is not always a one-way street. If he wishes help, the Veteran cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. at 192. While VA has a duty to assist the Veteran in the development of a claim, that duty is not limitless. In the normal course of events, it is the burden of the Veteran to appear for VA examinations. If he does not do so, there is no burden on the VA to "turn up heaven and earth" to find him. Hyson v. Brown, 5 Vet. App. 262 (1993). The Board has considered the Veteran's contention that a relationship exists between his psychiatric disability and his period of service during the Vietnam Era. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). In this capacity, the Board finds that, while the Veteran is competent to attest to his symptomatology related to his psychiatric disability, however, he is not competent to provide an opinion that he has a psychiatric disorder due to service, to include his service in the Vietnam, as he does not have the requisite medical expertise. Further, a psychiatric disorder was not diagnosed during the Veteran's period of active military service and, despite his contentions that he experienced psychiatric symptoms since such service, records show that he was diagnosed with a psychiatric disorder starting in the mid-1990s, not right after his Vietnam Era service. The negative clinical and documentary evidence post service for approximately 20 years after his Vietnam Era service is more probative than the remote assertions of the Veteran. The lack of continuity of treatment may bear in a merits determination on the credibility of the evidence of continuity of symptoms by lay parties. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In sum, the Board is left with no documented complaints or findings of a diagnosed psychiatric disorder in service, with documented subjective complaints of psychiatric symtoms in the mid-1990s and, most importantly, no medical opinion to support the Veteran's claim. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive evidence and negative evidence. The preponderance of the evidence now of record is against the Veteran's claim of service connection for a psychiatric disability including PTSD. Finally, the Board notes that a July 2003 record indicates that the SSA found the Veteran suffering from PTSD and hypertension, and held him to be totally disabled since January 1997. While the Board recognizes the disabling nature of the Veteran's psychiatric disability, the SSA decision is not considered sufficient to overcome the objective evidence of record as to the origin of the Veteran's claimed acquired psychiatric disorder, including PTSD. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. ____________________________________________ D. J. DRUCKER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs