Citation Nr: 1314744 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 06-28 500 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD) based on an in-service personal assault. 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to expressly include major depressive disorder and schizoaffective disorder. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1974 to January 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Portland, Oregon Department of Veterans Affairs (VA) Regional Office (RO), which denied the benefits sought on appeal. The Board recognizes that the Veteran's appeal was originally limited to a single issue of entitlement to service connection for PTSD. However, the record reflects that he also has been treated for major depressive disorder, schizoaffective disorder, and related mental health problems, all of which he has attributed to his active service. Therefore, given that current VA law dictates that service-connection claims for PTSD effectively contemplate all psychiatric disorders of record, the Board has recharacterized the Veteran's appeal as reflected on the title page of this decision. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Additionally, the Board observes that this case was previously remanded in October 2008, June 2010, and in August 2012. The Board finds that its prior remand directives have been met with substantial compliance by the agency of original jurisdiction (AOJ) such that appellate review may proceed. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Finally, while the Veteran has recently submitted argument in support of his appeal directly to the Board for initial review, he has expressly waived RO consideration of that new evidence. As such, another remand is unnecessary in order to comply with the provisions of 38 C.F.R. § 20.1304(c) (2012). FINDINGS OF FACT 1. The Veteran's currently diagnosed PTSD is causally related to an in-service sexual assault. 2. The Veteran's acquired psychiatric disorders, other than PTSD, but to expressly include major depressive disorder and schizoaffective disorder, were not caused or aggravated by any aspect of his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD based on an in-service personal assault have been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304(f)(5) (2012). 2. The criteria for service connection for an acquired psychiatric disorder other than PTSD, but to include major depressive disorder and schizoaffective disorder, have not been met. 38 U.S.C.A. §§ 1110, 1131, 1133, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.304, 3.307, 3.309, 3.384, 4.9, 4.125(a), 4.127 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) delineates VA's duties to notify and assist claimants in substantiating a application for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Specifically, that statute directs that, upon receipt of a complete or substantially complete application, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In this case, VA's duty to notify was effectively met through VCAA letters issued in November 2004, December 2008, and January 2009. Those letters collectively apprised the Veteran of the evidence needed to substantiate his acquired psychiatric disorder claims. They also informed him of his responsibilities, and those of VA, in obtaining relevant evidence, and described in detail how VA assigns a disability rating and an effective date following the grant of service connection. Therefore, those letters not only satisfied the original VCAA notice requirements but also the heightened requirements set forth in Dingess. In addition, the December 2008 letter expressly advised the Veteran of the specific alternate forms of evidence that he could use to substantiate his claim for service connection for PTSD based on in-service personal assault. See 38 C.F.R. § 3.304(f)(5) (2012). The Board recognizes that the December 2008 and January 2009 VCAA notice letters were mailed to the Veteran following the initial adjudication of his psychiatric claims. Nevertheless, the Board finds that any prejudice arising from such late VCAA notice has been cured by the subsequent readjudication of those claims in supplemental statements of the case (SSOCs) issued in March 2010 and February 2013. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant notification letter followed by readjudication of the claim, such as a statement of the case or SSOC, is sufficient to cure a timing defect). In those readjudications, the AOJ considered all of the pertinent evidence of record, including the clinical findings and lay argument that had been elicited on remand. Accordingly, the Board finds that the delay in VCAA notice has neither deprived the Veteran of effective participation in the processing of his service-connection claims nor affected the essential fairness of the decision. As such, VA's duty to notify under 38 C.F.R. § 3.159(b) has been effectively met with respect to those issues. Similarly, VA's duty to assist has been effectively met such that no further assistance is necessary. Through its initial development of the Veteran's appeal, and in accordance with the Board's prior remands, the AOJ has elicited information from the Veteran regarding the alleged personal assault stressors upon which his claim for PTSD is predicated. See 38 C.F.R. § 3.304(f)(5) (2012). The AOJ also has obtained the Veteran's service and post-service treatment records, as well as documentation from the Social Security Administration (SSA), which pertains to his application for SSA disability compensation based on schizophrenia and related psychiatric symptoms. Tellingly, the Veteran has not alleged that there are any other outstanding records relevant to the issues on appeal. As such, there is no need for additional records development with respect to those claims. Nor is there any need for an additional VA examination or medical opinion. To the contrary, the Veteran has already been afforded November 2009 and August 2010 VA mental health examinations, which have yielded medical opinions that have proven critical to the Board's decision to grant his PTSD claim. Such a favorable outcome, in tandem with the lack of any complaint from the Veteran, or other evidence of record, suggesting that the prior VA examination findings were inadequate to decide his appeal, leads the Board to conclude that an additional examination or medical opinion would be unnecessary. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board also considers it unnecessary to otherwise delay adjudication of the Veteran's appeal as its latest remand has met with substantial compliance by the AOJ. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As noted previously, the AOJ has conducted appropriate efforts to verify the Veteran's alleged in-service stressors, procure his service and post-service treatment records, and obtain VA examinations and medical opinions that are sufficient to decide his claims. As such, the Board is satisfied that the AOJ has achieved substantial, if not total, compliance with the terms of its prior remands. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); D'Aries v. Peake, 22 Vet App. 97, 105 (2008) (discussing situations when it is acceptable, instead, to have "substantial" compliance, even if not "exact," "total" or "complete" compliance, per se). In further compliance with the Board's latest remand, the Veteran's claims were most recently readjudicated in a February 2013 SSOC. In that readjudication, the AOJ explicitly considered the SSA and VA records that were associated with the claims file subsequent to the prior SSOC in October 2011. Even assuming, without conceding, that there are other relevant additions to the claims file that have not been expressly addressed, "[t]here is a presumption of regularity that public officers perform their duties 'correctly, fairly, in good faith, and in accordance with law and governing regulations.'" Marsh v. Nicholson, 19 Vet. App. 381, 385 (2005) (quoting Alaska Airlines, Inc. v. Johnson, 8 F.3d 791, 795 (Fed. Cir. 1993)). Courts presume that, "'in the absence of clear evidence to the contrary,'" public officers have "'properly discharged their official duties,'" Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (quoting United States v. Chem. Found., Inc., 272 U.S. 1, 14-15 (1926)). Therefore, absent any showing to the contrary, the Board presumes the AOJ has met its obligation to consider all evidence added to the record since the previous adjudication of the Veteran's claim. See 38 C.F.R. § 19.31 (2012). Significantly, neither the Veteran nor his representative has alleged or shown that this particular duty has not been satisfied. Thus, the presumption of regularity has not been rebutted and the Board concludes that there has been substantial compliance with its prior remand directives, including its instruction to readjudicate the Veteran's claim after additional development was completed. See Stegall, 11 Vet. App. at 271. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied with respect to his service-connection claims and, thus, appellate review of those issues may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). B. Legal Criteria, Factual Background, and Analysis At the outset of its discussion, the Board notes that, while it has reviewed all of the written argument, medical records, examination reports, and other documentation in the Veteran's paper claims file and Virtual VA efolder, its emphasis has rested on the evidence relevant to the matters decided herein. The Board recognizes that it has an obligation to provide adequate reasons and bases in support of its decision. However, it need not address every scintilla of evidence contained in the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the salient evidence as appropriate and focus its analysis specifically on what that evidence shows, or fails to show, with respect to the Veteran's claims. The Veteran contends that he developed PTSD and other acquired psychiatric disorders, including major depression and schizophrenia, in the wake of an in-service sexual assault. As such, he maintains that service connection is warranted for all of those disabilities. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Additionally, when, as in the instant case, a Veteran had 90 days or more of continuous, active service, service connection shall be rebuttably presumed for certain chronic diseases, such as psychoses, which manifest to a compensable degree within one year following the date of release from service. See 38 U.S.C.A. § 1133; 38 C.F.R. §§ 3.307, 3.309. During the pendency of this appeal, 38 C.F.R. § 3.384 was added to further define a "psychosis" to include brief psychotic disorder; delusional disorder; psychotic disorder due to general medical condition; psychotic disorder not otherwise specified; schizoaffective disorder; schizophrenia; schizophreniform disorder; shared psychotic disorder; and substance-induced psychotic disorder. See 71 Fed. Reg. 42758 (Jul. 28, 2006) (final rule implementing 38 C.F.R. § 3.384, effective August 28, 2006). Regardless of the applicability of the above provisions, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In this regard, the Board notes that the presumptive provisions of VA statutes and regulations are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. As such, those provisions are not intended to limit VA benefits to diseases so diagnosed when the evidence warrants service connection on a direct basis. Id. To prevail in a claim for direct service connection, there generally must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. See Hickson v. West, 12 Vet. App. 247 (1999). In addition to the foregoing general requirements, the elements for establishing service connection for PTSD include (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The Board acknowledges that, during the pendency of this appeal, VA amended its regulatory provisions governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing a claimed in-service stressor. The amendments, which took effect July 13, 2010, redesignated current paragraphs (f)(3) and (f)(4) of 38 C.F.R. § 3.304(f) as paragraphs (f)(4) and (f)(5), respectively, and added a new paragraph (f)(3) that states (with added emphasis): 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 that 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. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire; including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The Board acknowledges that the Veteran's PTSD claim does not appear to have been readjudicated in accordance with the revised regulation governing hostile military and terrorist activity. 38 C.F.R. §§ 3.304(f)(3) (2012). Nevertheless, the Board finds that consideration of that amendment is unnecessary as the particular stressor to which the Veteran attributes his PTSD involves neither type of activity. Rather, the Veteran's PTSD claim is predicated on a history of military sexual assault. 38 C.F.R. § 3.304(f)(5) (2012). While the particular regulatory provision governing that type of in-service stressor has been renumbered, effective July 13, 2010, its substance has not changed. Specifically, 38 C.F.R. § 3.304(f)(5) directs that, in claims for PTSD based on personal assault, evidence from sources other than service records may corroborate the appellant's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the appellant's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5) (2012). Here, in response to VA's queries, the Veteran has submitted detailed written descriptions of the circumstances surrounding his alleged in-service assault. Specifically, he has alleged that the attack occurred in the winter of 1975, when he was serving aboard the USS Ogden. The Veteran has indicated that he was accosted in the ship's boiler room by three fellow sailors, two of whom pinned him to the ground while the third forced him to engage in anal intercourse. He has reported that, once the assault was over, the other sailors warned him to keep silent and threatened to kill him "if he ever said anything." Notwithstanding those threats, the Veteran has professed that he did, in fact, notify his superior officer about the assault. However, he has acknowledged that no disciplinary action was taken since his assailants all denied his allegations. In essence, the Veteran has claimed that it was "[his] word against theirs, so the [charges] were dropped." He has not reported any further episodes of in-service assault or retaliation following the rape. Nevertheless, he has maintained that this attack, while isolated, inflicted lasting damage on his psyche, triggering nightmares, flashbacks, social withdrawal tendencies, depression, and related mental health problems, which have severely impaired his social and occupational functioning. The Veteran's assertions are not corroborated by his service treatment records, which are silent for any complaints or clinical findings of rape or ensuing psychiatric problems. Nevertheless, the Board observes that such a lack of contemporaneous clinical documentation does not render the Veteran's account of in-service trauma inherently incredible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Indeed, that is particularly true where, as here, the alleged trauma involves a sexual assault. Accordingly, the Board has afforded careful consideration to the other pertinent evidence in the Veteran's paper claims file and Virtual VA efolder. Such evidence includes his VA and Vet Center treatment records, which are replete with complaints and clinical findings of anxiety, depression, intrusive thoughts, nightmares, irritability, auditory hallucinations, and concentration deficits. Those symptoms have been found to comport with Axis I diagnoses of PTSD, major depressive disorder, and schizoaffective disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). In addition to receiving psychotherapy and medication for the above conditions, the Veteran has been treated for behavioral disorders, persisting since childhood, which have been manifested by illicit drug use and sexual abuse of a minor. In this regard, the Board acknowledges that VA law prohibits a grant of direct service connection for drug or alcohol abuse, or other illicit activity. 38 U.S.C.A. §§ 1110, 1131 (West 2002); Pub. L. No. 101-508, § 8052, 104 Stat. 1388, 1388- 351 (1990); VAOPGCPREC 2-98 (Feb. 10, 1998), 63 Fed. Reg. 31263 (1998). Nevertheless, service connection may still be granted where the illicit activity is shown to be a secondary disability, or symptom, of an acquired psychiatric disorder, which was caused or aggravated in service and is not itself the product of willful wrongdoing. Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). Similarly, while personality disorders are not considered diseases or injuries for VA benefits purposes, service connection may still be established if the evidence shows that an acquired psychiatric disorder was incurred in service and superimposed upon the preexisting personality disorder. 38 C.F.R. §§ 4.9; 4.125(a), 4.127 (2012); Carpenter v. Brown, 8 Vet. App, 240 (1995); Beno v. Principi, 3 Vet. App. 439 (1992). Thus, for the purpose of this appeal, the Board must consider whether the Veteran's illicit drug use and sexual abuse history constitute secondary disabilities, or symptoms, of the acquired psychiatric disorders for which he seeks service connection. The Board must also consider whether any such psychiatric disorder arose in service and was superimposed upon a preexisting personality disorder. The overall complexity of the Veteran's psychiatric history previously led the Board to request a VA examination in support of his claims. Such an examination was administered in November 2009. At that time, the Veteran recounted his history of in-service sexual assault. He also reported a pattern of nonservice-related physical and sexual abuse, which he had first incurred as a child from his father and then perpetrated as an adult on his own daughter. In addition, the Veteran acknowledged a long history of substance abuse, but emphasized that he had been sober for 14 years. He added that he now relied on prescription medications to treat his wide-ranging physical and psychiatric problems. During a contemporaneous mental status evaluation, the Veteran was cooperative and exhibited "fair" eye contact and linear thought processes. However, he endorsed multiple psychotic and neurotic tendencies, including auditory hallucinations, feelings of hopelessness, intrusive thoughts, irritability, exaggerated startle response, social isolation, concentration deficits, and a general sense of "being nervous and on guard." After reviewing the results of the examination, as well as the other pertinent evidence of record, the examining VA psychiatrist confirmed the Veteran's prior Axis I diagnosis of chronic PTSD. The VA examiner also acknowledged the Veteran's previous diagnoses of schizoaffective disorder and major depression, but indicated that those conditions were neither actively present nor related to his military sexual trauma. Conversely, the examiner determined that the Veteran's PTSD was as likely as not related to that in-service personal assault stressor, which the examiner opined and accepted as true, notwithstanding the lack of objective verification. The examiner essentially reached the same conclusion following a subsequent VA examination in August 2010. The Board recognizes that the above VA examiner did not support his medical opinions with a detailed rationale. Nevertheless, those opinions were predicated on comprehensive clinical interviews and mental status evaluations, as well as complete reviews of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The Board recognizes that claims file review is not a strict prerequisite for medical opinions, even those authored by VA examiners. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Nevertheless, the probative value assigned to a medical opinion may be reduced if the clinician fails to acknowledge relevant information, particularly that which is contrary to the opinion. Conversely, greater reliance may be placed on an opinion rendered by an examiner who is fully informed of the pertinent factual premises (i.e., history) of the appeal. See Nieves-Rodriguez, 22 Vet. App. at 302. Such is the case here. Indeed, the examiner who authored the November 2009 and August 2010 VA medical opinions demonstrated his understanding of the pertinent facts underlying the Veteran's claims by taking into account his own reported history, as well as his clinical manifestations, and conducting a thorough evidentiary review. As such, the Board is satisfied that the examiner duly considered all salient evidence, both clinical and lay. Id. Moreover, while additional records of mental health treatment, SSA documentation, and written argument has since been added to the claims file, none of that recent evidence conflicts with the VA examiner's opinions. Therefore, notwithstanding the passage of time since those opinions were rendered, the Board considers it probative for the purpose of deciding the Veteran's claims. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (noting that the mere passage of time does not automatically render an examination inadequate for VA rating purposes). Additionally, the Board considers it significant that the November 2009 and August 2010 VA opinions were rendered by a licensed physician with specialized training in the psychiatric disorders at issue in this appeal. Such documented clinical expertise further bolsters the overall weight of that examiner's findings. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997) (in determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data). Moreover, while mindful that the above VA examiner predicated his positive nexus opinions on an in-service stressor that had not been independently verified, the Board considers this to have been appropriate course of action. Indeed, it is the responsibility of each VA examiner to duly consider all competent evidence of record, and to reserve the Board's right to determine the overall weight of that evidence in the final adjudication of the appeal. See Layno v. Brown, 6 Vet. App. 465, 469 (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")); see, also, Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). As such, the VA examiner demonstrated the proper deference for the Veteran's lay history, which concerned an assault in service that he had personally experienced and was therefore competent to report. See Layno, 6 Vet. App. at 470. Having thus established that the November 2009 and August 2010 VA opinions are worthy of reliance, the Board finds that these opinions support a grant of the Veteran's PTSD claim. Indeed, the VA examiner who authored those opinions was unequivocal that the Veteran's current PTSD symptoms were predicated, at least in part, on his reported military sexual trauma. In reaching this determination, the Board is mindful that the Veteran's account of in-service sexual trauma has not been independently verified. Moreover, the Board recognizes that, in contrast with the VA examiner, it is obligated to make a credibility determination with respect to the occurrence of that claimed stressor. See Layno v. Brown, 6 Vet. App. 465, 469 (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')); see, also, Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). However, notwithstanding the lack of objective corroboration, the Board finds that the overall evidence of record is sufficient to substantiate that stressor's existence for the purposes of this appeal. In this regard, the Board notes that the Veteran's account of service aboard the USS Ogden is expressly corroborated by his service personnel records. Moreover, the Board finds his assertions of military sexual trauma to be consistent with the circumstances of his service as established through his internally consistent, unrefuted, and therefore credible written statements and transcribed oral history. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). Similarly, the Board observes that the occurrence of the Veteran's claimed in-service stressor is evident through his documented behavior changes, which include not only longstanding occupational impairment but also substance abuse, episodes of depression, panic attacks, and anxiety. Such behavioral changes are expressly included in the list of factors that may be used to establish the incurrence of an personal assault stressor under 38 C.F.R. § 3.304(f)(5). Moreover, while cognizant that those behavioral changes have also been linked to pre-service and post-service traumatic events, the Board nevertheless considers them to be consistent with the Veteran's account of an in-service rape. In this regard, the Board observes that there is nothing in 38 C.F.R. § 3.304(f)(5), or any other VA law, which states that symptoms attributable to in-service and non-service events must be mutually exclusive. It follows that the Board has no adequate basis to reject the circumstantial evidence of record, which supports the Veteran's competent and credible lay assertions with respect to his in-service personal assault. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). Having thus accepted the veracity of the Veteran's alleged in-service stressor, the Board has no discretion but to also accept the November 2009 and August 2010 VA medical opinions relating that stressor to his currently diagnosed PTSD. As discussed earlier, those opinions are uncontroverted by the other evidence of record. As such, the Board is precluded from exercising its own judgment to reach a different conclusion. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Accordingly, the Board finds that the overall evidence of record is sufficient to show that the Veteran's currently diagnosed PTSD is causally related to an in-service stressor based on sexual assault. Consequently, the Board finds that the requirements for direct service connection for PTSD have been met in this case. See Hickson, supra; 38 C.F.R. § 3.304(f). Conversely, the Board finds that the requirements for direct service connection have not been met with respect to any other currently diagnosed acquired psychiatric disorder. In particular, while major depression and schizophrenia also have been diagnosed during the pendency of this appeal, the November 2009 VA examiner has expressly declined to relate either disorder to the Veteran's active service. Just as the Board may not independently reject that examiner's positive nexus opinion with respect to PTSD, it also may not discount his countervailing findings with respect to the Veteran's other acquired psychiatric diagnoses. See Colvin, supra. Indeed, both the examiner's positive and negative nexus opinions are unchallenged by any competent evidence of record. In this regard, the Board recognizes that the Veteran is of the opinion that his depression and schizophrenia are related to his service. However, while he is competent to attest to a history of in-service and post-service nightmares, intrusive thoughts, irritability, social isolation, and related mental health symptoms, all of which are capable of lay observation, he has not shown that he has the expertise to comment on complex medical issues, such as the nature and etiology of his currently diagnosed psychiatric disorders. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms, but not to speak as to etiology except in limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg.). As such, the relationship, if any, between the Veteran's current psychiatric disabilities and the symptoms he reports having during his active service, is a matter that requires medical expertise to resolve. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that "[a]lthough the Veteran is competent to testify to the pain he has experienced since his [active service], he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with"). That is particularly true where, as here, the Veteran's overall psychiatric disability picture is inherently complex. In addition to being diagnosed with multiple acquired psychiatric disorders, the Veteran has been treated for longstanding behavioral disturbances manifested by illicit drug and sexual abuse. In view of that complicated medical history, the Board finds that the etiology of the Veteran's mental health problems can only be resolved by a clinical expert, such as the author of the November 2009 VA opinion. That clinician's demonstrated expertise in diagnosing and treating psychiatric disorders adds to the probative weight of his opinion, relative to the less informed views of the Veteran. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997) (in determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data). Moreover, the Board considers it significant that, despite tacitly disagreeing with the November 2009 VA examiner, the Veteran has not alleged that this clinician was unqualified to render etiological findings in connection with this appeal. Nor has the Veteran submitted any evidence refuting those findings or showing, in the alternative, that he himself is qualified to ascribe his current depression and schizophrenia to a personal assault or other injury or disease in service. Therefore, the Board finds that the Veteran's own views in this regard are outweighed by the November 2009 negative nexus opinion. Next, the Board acknowledges that, under prior VA law, the nexus requirement could be satisfied through a continuity of symptomatology, which could be established under certain circumstances through lay evidence. See 38 C.F.R. § 3.303(b) (2012). However, the United States Court of Appeals for the Federal Circuit has since ruled that this is no longer the case with respect to disabilities, such as depression, which fall outside the ambit of 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Accordingly, even assuming, without conceding, that a continuity of depression symptoms had been shown in this case, such a showing would no longer serve as a sufficient substitute for the third and final Hickson element. See Hickson, 12 Vet. App. at 253. Conversely, the Veteran's schizophrenia constitutes a psychosis, which is recognized as a chronic disease under 38 C.F.R. § 3.309(a). Therefore, service connection for that psychiatric disorder may still be established through a showing of continuity of symptomatology. However, no such showing has been made here. To the contrary, notwithstanding the Veteran's assertions of in-service incurrence, he has not contended, and the record does not otherwise show, that the auditory hallucinations and other psychotic symptoms underlying his schizophrenia have persisted on a continuous basis since his active service. Consequently, the Veteran may not rely on the theory of continuity of symptomatology to prevail in his claim for service connection for that particular chronic disease. Furthermore, the Board observes that, with respect to both schizophrenia and all other non-PTSD disorders, the record is markedly devoid of any relevant mental health complaints or clinical findings at the time of the Veteran's discharge or for many years thereafter. As noted previously, the mere absence of contemporaneous clinical data is not a sufficient stand-alone basis to deny the Veteran's claim. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (2006). Nevertheless, such an unexplained evidentiary is another factor that weighs against that claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting 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 during the active military service and resulted in a chronic or persistent disorder). In light of the foregoing, the Board finds that, while the Veteran has met the first two requirements for direct service connection- existence of a current disability and in-service incurrence/aggravation - he has not satisfied the final element (nexus) with respect to any acquired psychiatric disorder apart from PTSD. See Hickson, 12 Vet. App. at 253. Accordingly, service connection for such a disorder is not warranted on a direct basis. Nor is service connection warranted on a secondary basis. To the contrary, there is nothing in the record to suggest that the Veteran's major depression and schizophrenia were caused or aggravated by his PTSD or by any other service-connected disorder. Similarly, there is no indication that the Veteran's documented behavioral disturbances, and underlying drug and sex abuse, in any way constitute secondary disabilities, or symptoms, of his service-related PTSD. Nor is there any indication that the latter superimposed itself upon any preexisting personality disorder such that service connection may be established for an additional qualifying disability. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. Moreover, the record does not show that schizophrenia, or any other chronic psychosis, manifested to a compensable degree within a year of the Veteran's release from service. As such, service connection is also not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309, 3.384. In sum, the Board finds that, while direct service connection is warranted for the Veteran's PTSD, he is not entitled to a separate award for his other acquired psychiatric disorders and behavioral disturbances. Nevertheless, the Board wishes to emphasize that, by receiving service connection for PTSD, the Veteran is effectively obtaining VA benefits for all of his underlying psychiatric symptoms, including those associated with other mental disorders for which VA benefits have not been formally established. See Clemons, supra; see also Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of the service-connected condition versus a nonservice-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant's favor, thus attributing such signs and symptoms to the service-connected disability). All reasonable doubt has been resolved in the Veteran's favor by reaching this decision. ORDER Service connection for PTSD is granted. Service connection for an acquired psychiatric disorder other than PTSD, to expressly include major depressive disorder and schizophrenic disorder, is denied. ____________________________________________ A. ISHIZAWAR Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs