Citation Nr: 1315237 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 11-01 421 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected migraine headaches. 2. Entitlement to an increased (compensable) rating for a service-connected corneal scar of the right eye. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty from January 1943 to April 1946, and from August 1946 to August 1948, with additional reserve service. He had a period of active duty for training from January 29, 1967 to February 21, 1967, during which he incurred his service-connected right eye disability. This period is also considered active military service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island, which denied an increased rating for the Veteran's service-connected corneal scar of the right eye, determined that new and material evidence has not been received to reopen a previously denied claim for a psychiatric disorder, and reopened a claim for service connection for posttraumatic stress disorder (PTSD) but denied it on the merits. A Travel Board hearing was held in May 2012 with the Veteran in Providence, Rhode Island, before the undersigned Veterans Law Judge, who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file. In a September 2012 decision, the Board consolidated the Veteran's claims for a psychiatric disorder and PTSD into a single issue pursuant to the holdings in Clemons v. Shinseki, 23 Vet. App. 1 (2009), and Boggs v. Peake, 520 F.3d 1330 (2008). The Board reopened that issue of entitlement to service connection for an acquired psychiatric disorder. That claim and the Veteran's claim for an increased rating for a right eye condition were then remanded for additional procedural and evidentiary development. Both claims now return to the Board for further review. The Veteran's Virtual VA file was also reviewed as part of his appeal. FINDINGS OF FACT 1. Major depressive disorder is not etiologically related to service or service-connected migraine headaches, and diagnoses of PTSD are not based upon verified stressors in service. 2. Manifestations of the Veteran's right eye corneal scar do not result in decreased visual acuity or other visual impairment. CONCLUSIONS OF LAW 1. An acquired psychiatric condition was not incurred in or aggravated by service, and is not proximately due to or aggravated by a service-connected disability; psychoses may not be presumed to have been incurred or aggravated by service. 38 U.S.C.A. § 1110, 1131, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for a compensable rating for a right eye corneal scar have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.14, 4.75, 4.79, Diagnostic Codes 6009, 6064 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to the initial adjudication of the Veteran's claims, letters dated in November 2008, March 2009, and April 2009 were sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claim; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claims. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He was also notified of the criteria for establishing an effective date and disability rating. See Dingess. A September 2012 letter also notified the Veteran of the criteria for establishing service connection as secondary to a service-connected disability. Here, the duty to notify was not satisfied prior to the initial decision on the Veteran's claims by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case (SOC) or supplemental statement of the case (SSOC), is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial AOJ decision by way of the September 2012 letter that addressed all notice elements, including the criteria for establishing service connection on a secondary basis. Although the notice letter was not sent before the initial RO decision in this matter, the Board finds that this error was not prejudicial to the Veteran because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the Veteran been afforded a meaningful opportunity to participate effectively in the processing of his claim and given ample time to respond, but the claim was then readjudicated by way of an SSOC in April 2013, after the notice was provided. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. See Shinseki v. Sanders/Simmons, 129 S.Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the United States Court of Appeals for Veterans Claims (Court) to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). B. Duty to Assist The Veteran's service treatment records, VA treatment records, private treatment records, lay statements and hearing transcript have been associated with the claims file. Notably, in the September 2012 remand, the Board instructed the RO to obtain outstanding VA and private treatment records that had been identified by the Veteran. A review of the claims file indicates that the VA records were obtained. In the September 2012 letter sent to the Veteran, he was asked to provide the necessary authorization for the release of his private records from Butler Hospital, and was notified that he may choose to submit those records himself. However, the Veteran did not submit the requested authorization or provide his own copies of the records in question. The Veteran was also afforded VA examinations for his claims, including two examinations conducted pursuant to the Board's September 2012 remand. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; record the relevant findings for rating the Veteran's right eye corneal scar, and provide an opinion regarding the etiology of the Veteran's psychiatric disability. With respect to the VA psychiatric examination, the Board notes that the examiner reviewed the claims file but did not provide specific comments regarding complaints of nervousness prior to 1979. However, there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012); see also Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). The U.S. Court of Appeals for Veterans Claims (Court) stated that examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo, 26 Vet. App. at 105. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). As the Veteran was provided with adequate VA examinations, and because appropriate efforts were made to obtain previously identified outstanding treatment records, the Board finds that the directives of the September 2012 remand have been satisfied. See Stegall v. West, 11 Vet. App. 268 (1998). As noted above, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in May 2012. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the Decision Review Officer (DRO) or VLJ who chairs a hearing must 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 hearing, the VLJ explained the issues and sought to elicit testimony and identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding, and which might substantiate the claims. Moreover, the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the hearings. By contrast, the hearings focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for benefits. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. In addition, the case was remanded to obtain outstanding, potentially relevant evidence; thereby, negating any prejudice. VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claims. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Service Connection A. Applicable Law In order to establish service connection for a claimed disability, the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). 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) (2012). In addition, certain chronic diseases, including psychoses, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). 38 C.F.R. § 3.384 provides that a "psychosis" for purposes of presumptive service connection specifically includes brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder NOS, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. For a showing of chronic disease in service, there is required a 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." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). However, service connection based on a theory of continuity of symptomatology is applicable only for those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2012). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. A finding of secondary service connection requires competent medical evidence to connect the asserted secondary disability to the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997). Prior to receipt of the Veteran's October 2008 claim, and effective October 10, 2006, 38 C.F.R. § 3.310 was amended in order to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995), regarding secondary service connection on the basis of the aggravation of a nonservice-connected disorder by a service-connected disability. See 71 Fed. Reg. 52744 (2006). The amended 38 C.F.R. § 3.310(b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. In this regard, the recent amendment to 38 C.F.R. § 3.310 provides, in pertinent part, that VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b) (2012). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. 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 facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition 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. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). B. Evidence Service treatment records from the Veteran's initial periods of active service are entirely negative for a psychiatric disorder, and post-service medical records which reflect long-term treatment for headaches with Librium and Fiorinal since 1966. In the Veteran's original claim for service connection in August 1948, his only claimed disabilities were headaches, a leg disability, an ear condition, and a dental condition. He did not claim service connection for a psychiatric disorder. A June 1949 VA examination reflects that the Veteran's only complaints related to a head injury and a leg injury incurred while playing sports in service. The examiner indicated that the Veteran was oriented and his memory was unimpaired. His chief complaint was headaches. The diagnostic assessment was cephalgia [headache] (subjective only). A July 1950 VA neuropsychiatric examination was performed to evaluate his claimed nervous condition, i.e., his headaches. The examiner noted that the Veteran's only current symptom was his complaint of recurrent headaches. The examiner stated that there were no other findings or other history that would classify the subjective complaint of headaches under a neuropsychiatric diagnosis. The only diagnosis was encephalalgia, type undetermined. Service connection for headaches was granted in an August 1950 rating decision. VA hospital records reflect that the Veteran was hospitalized from April to May 1952 for a pilonidal cyst; hospital records show that his past history was essentially negative except that he had headaches for four years. These records are negative for a psychiatric disorder. Multiple medical examinations were performed during the Veteran's several decades of reserve service after his 1948 separation from active duty service. His psychiatric system was listed as normal on all of these examinations. Moreover, the Veteran repeatedly denied nervous trouble, depression or excessive worry in his reports of medical history. A March 1968 VA examination shows that the Veteran complained of a right eye problem, headaches and nervousness. On neuropsychiatric examination, the examiner indicated that as far as his psychiatric condition, which was previously diagnosed as encephalgia, or recurring headaches, there had been little change. The examiner noted that he was moderately tense, but that there was no emotional background to the headaches. The only diagnosis was encephalgia. A patient problem list dated December 1973 noted chronic anxiety. A September 1978 VA outpatient treatment record reflects that the Veteran was anxious and crying when reporting that his wife was seriously ill; the diagnostic assessment was cephalalgia/anxiety. In February 1979, the diagnostic assessment was an increase in situational stress due to the impending loss of his wife. The nurse indicated that his grief reaction appeared normal. Subsequent VA medical records reflect treatment for anxiety exacerbated by concerns about his adult daughter's welfare and the status of his relationship with his girlfriend. In May 1981, the Veteran reported a one and a half year history of depression following the death of his wife. VA inpatient medical records dated in 1985 show that the Veteran reported being first treated with Valium shortly after service. He was in the reserves for 30 years and was about to retire. The examiner indicated that he had been maintained primarily on Librium and Valium over the years. The examiner opined that the Veteran had an obsessive compulsive personality structure and was constantly challenged when things weren't "right" beginning from the time when he was in the war. He also opined that there was an element of unresolved grief reaction regarding his wife's death. On VA psychiatric examination in April 1990, the Veteran denied combat, but reported being in plane crashes. He was diagnosed with anxiety disorder versus PTSD. On VA neurological examination in April 1990, the Veteran reported a history of severe headaches since 1943 after several plane crashes that were exacerbated by the development of PTSD. On VA examination in November 1995, the examiner diagnosed generalized anxiety disorder, and found no current PTSD. He stated that the headaches were also conceivably part of his generalized anxiety disorder. In January 1996, the Veteran reported ongoing flashbacks of combat experiences, guilt related to service, and ruminations of death and the loss of numerous significant people in his life such as his wives and a girlfriend. The diagnoses were major depression, rule out generalized anxiety disorder, and a history of PTSD. Additional records from February 1997 reflect diagnoses of major depression and PTSD from combat. VA records from December 1999 show findings of depression after the Veteran's day-trading "went sour." Additional private medical records dated in January 2000 from Butler Hospital reflect treatment for psychotic disorder, not otherwise specified (NOS), and generalized anxiety disorder. It was noted that he had delusional paranoias status post financial catastrophe. The Veteran reported that he had intermittent major depressive episodes over the last 20 years. Subsequent VA medical records dated from 2007 to 2009 reflect treatment for depression and anxiety, as well as a diagnosis of bipolar disorder. In a January 2009 statement, the Veteran indicated that he saw a man killed while attempting to corral a blimp in the process of landing. In a separate statement, he reported that he had served as a radar operator on board an aircraft. He had returned from a routine patrol, but one of the other planes had not. He went back out to search for the missing aircraft, but nothing was ever found. At his May 2012 Board hearing, and in additional written statements, the Veteran testified that he had experienced symptoms of anxiety ever since his period of active duty. A September 2012 VA examination diagnosed major depression, and the examiner specifically stated that the Veteran did not have more than one diagnosed mental disorder. He further stated that the clinical records did not support a diagnosis of depression since service. Rather, records indicated that depression first became significant in the late 1970's and 1980's after the Veteran's wife died in 1979. The examiner cited a clinical interview in 1985 in which the Veteran reported that "the rug had been pulled out from under him" when she died before they could spend retirement together. He had also lost his elder brother at that time. Records from 2000 show the Veteran reported depression first began "20 years ago." Subsequent records showed depression related to financial losses, and more recent records indicated that the Veteran's depression stems from the loss of his friends, his wife, and his siblings. In addition, he did not describe any depressive symptoms as secondary to headaches, and there was no evidence of this in his clinical records. With respect to service, the Veteran reported that he had learned sometime during service that a childhood friend had died during the war. He also said a plane went missing while he was in service, and he sometimes pictured the plane being at the bottom of the ocean and felt sad. He denied experiencing a significant traumatic stressor in service and denied all symptoms of PTSD. For these reasons, the examiner concluded that it was less likely than not that the Veteran's major depressive disorder was caused by or a result of military service, or was caused or aggravated by his service-connected headache disorder. C. Analysis The criteria for service connection for PTSD differ slightly from the criteria for basic service connection and will be addressed separately. 1. PTSD Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV)); (2) a link, established by medical evidence, between current PTSD symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2012). If VA determines that a veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran's lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f). No further development or corroborative evidence is required, provided that the claimed stressor is "consistent with the circumstances, conditions, or hardships of the veteran's service." Id. The Board notes that effective July 13, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010). Specifically, the final rule amended 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (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 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. With respect to the Veteran's stressors, his discharge documents do not reflect service in combat, and he denied any combat experiences during VA examinations in April 1990 and September 2012. Although separate records reflect reports of combat flashbacks, the overall weight of the evidence is against a finding that the Veteran served in combat during his periods of service. Therefore, the February 1997 diagnosis of "PTSD from combat" is insufficient to establish service connection because combat has not been verified as a stressor. Similarly, the Veteran has not identified any specific stressors related to his fear of hostile military or terrorist activity. Therefore, the provisions of 38 C.F.R. § 3.304(f)(3) are not applicable. The Veteran reported specific stressor incidents in service. First, he stated that he witnessed a man die during a blimp landing. However, the relevant unit information and dates for this incident were forwarded to the Defense Personnel Records Image Retrieval System, which responded that the available records did not reflect any casualties for the relevant period and locations. Second, he reported that a plane went missing during one of his patrols, and he reported being involved in plane crashes. While these claimed stressors have not been investigated, the available records do not reflect a diagnosis of PTSD attributable either event. The September 2012 VA examiner specifically noted the Veteran's report of the missing plane, but stated that he did not meet the criteria for a diagnosis of PTSD. The Veteran denied any other significant traumatic experiences during service. In sum, while the evidence reflects diagnoses of PTSD at various times after service, none of these diagnoses have been attributed to a verified stressor in service or a stressor related to the Veteran's fear of hostile military or terrorist activity. Therefore, service connection for PTSD is not warranted. 2. Psychiatric Disorder Other Than PTSD The Veteran was diagnosed with a compulsive personality structure beginning from the time he was in the war. Personality disorders are not diseases or injuries under VA regulations and therefore are not disabilities for which service connection can be granted. 38 C.F.R. § 3.303(c). Nevertheless, service connection may be granted if the evidence shows that an acquired psychiatric disorder was incurred or aggravated in service and superimposed upon the preexisting personality disorder. 38 C.F.R. §§ 4.9; 4.125(a), 4.127 (2010); Carpenter v. Brown, 8 Vet. App, 240 (1995); Beno v. Principi, 3 Vet. App. 439 (1992). The evidence reflects a number of other diagnosed psychiatric conditions, including depressive disorder, generalized anxiety disorder, bipolar disorder, and delusional paranoias. However, the overall weight of the evidence is against a finding that any of these conditions are etiologically related to service. There are no competent medical opinions attributing any of the listed conditions to the Veteran's period of service. The September 2012 VA examiner diagnosed major depression and specifically stated that it was not caused by or related to service. This opinion was based on a review of the claims file, a history provided by the Veteran, and an examination. There is no competent medical opinion to refute this conclusion or to otherwise suggest that the Veteran has a current psychiatric disorder related to service. The Board has considered the Veteran's own statements made in support of his claim. However, he has not demonstrated the necessary knowledge or expertise to render specific diagnoses of complex psychiatric conditions or offer opinions on their etiology. Therefore, his statements are not competent medical evidence. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), the onset and/or etiology of a psychiatric disorder falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." The Veteran has also reported experiencing continuous symptoms of depression or anxiety since his period of service in the 1940's. As noted above, however, service connection based on a theory of continuity of symptomatology is applicable only for those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the applicable chronic disability is "psychosis." Of all the Veteran's diagnosed conditions, only his delusional paranoias fall within the definition of psychoses found in 38 C.F.R. § 3.384. However, delusional paranoias were specifically attributed to his financial setbacks in 1999 and 2000. There are no other records of a delusional disorder or other psychosis. Finally, the overall weight of the evidence is against a finding that the Veteran has a psychiatric disability that is caused or aggravated by his service-connected headaches. The September 2012 examiner specifically noted that the Veteran did not describe any depressive symptoms as secondary to headaches, and there was no evidence of this in his clinical records. A March 1968 examination noted complaints of headaches and nervousness. However, the examiner indicated that as far as the Veteran's psychiatric condition, which was previously diagnosed as encephalgia, there has been little change. The examiner noted that he was moderately tense, but that there was no emotional background to the headaches. A separate psychiatric disorder was not diagnosed. The preponderance of the evidence is against finding that the Veteran has an acquired psychiatric disorder etiologically related to active service or a service-connected disability. The appeal is accordingly denied. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) regarding benefit of the doubt, but there is not such a state of equipoise of positive and negative evidence to otherwise grant the Veteran's claim. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). As noted in the September 2012 remand, in addition to his corneal scar, the Veteran has been diagnosed with other right eye conditions which are not service-connected. An April 2009 VA examination noted that the Veteran also had central retinal vein occlusion with focal laser treatment, cataracts, and glaucoma. All of these conditions were determined to be unrelated to his service-connected corneal scar. The use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation is to be avoided. 38 C.F.R. § 4.14. The Veteran's treatment records during the period on appeal indicate that overall right eye visual acuity was limited to "hand motion at 1 foot" or "count fingers at 1.5 feet." Therefore, in order to determine the level of impairment resulting solely from the Veteran's service-connected corneal scar, he underwent another VA examination in September 2012. The examiner reviewed the claims file, obtained a history from the Veteran, and conducted a physical examination. He stated that the Veteran's corneal scar was the result of a herpes simplex keratitis episode in 1967. The current state of his scar was similar to the description noted in 1967 - "faint diffuse superficial haziness of the central region of the cornea." The examiner stated that the visual impairment from the corneal scar would therefore be the same as it was in 1967, which was 20/30. The examiner stated that the Veteran's severe degree of right eye visual impairment was due to the dense cataract, central retinal vein occlusion, and subsequent laser focal treatment. The September 2012 VA examiner's opinion is the only evidence from the period on appeal which distinguishes visual impairment caused by nonservice-connected right eye conditions from impairment caused by the service-connected corneal scar. There is no other competent evidence to indicate that the Veteran's corneal scar, alone, results in visual acuity of less than 20/30 as indicated by the examiner. The May 2009 rating decision on appeal indicates that the Veteran's right eye disability is rated under Diagnostic Codes 6009-6079. The rating criteria used to evaluate disabilities of the eyes were amended as of December 10, 2008, for all claims filed on or after such date. As the Veteran's claim was filed in March 2009, only the new rating criteria apply in the present case and consideration of prior regulations is not required. Under the current criteria, the Veteran's right eye disability is rated based on visual impairment or incapacitating episodes, whichever results in a higher evaluation. When only one eye is service-connected, subject to the provisions of 38 C.F.R. § 3.383(a), the visual acuity of the other eye will be considered to be 20/40 for the purposes of evaluating the service-connected visual impairment. 38 C.F.R. § 4.75(c). Diagnostic Code 6066 assigns a 0 percent rating for visual acuity of at least 20/40 in both eyes. 38 C.F.R. § 4.79, DC 6066. Impairment of visual acuity is determined based on the best distant vision obtainable. 38 C.F.R. § 4.76(b). Because the Veteran's right eye corneal scar results in visual acuity of 20/30, and because his non-service connected left eye is considered to be 20/40, the currently assigned noncompensable rating is appropriate. Under 38 C.F.R. § 3.383(a)(1), compensation is payable for the combinations of service-connected and nonservice-connected disabilities, as if both disabilities were service-connected, provided the nonservice-connected disability is not the result of the Veteran's own willful misconduct. With respect to the eyes, this applies when there is impairment of vision in one eye as a result of service-connected disability and impairment of vision in the other eye as a result of nonservice-connected disability and the impairment of vision in each eye is rated at a visual acuity of 20/200 or less; or the peripheral field of vision for each eye is 20 degrees or less. 38 C.F.R. § 3.383(a)(1). In this case, however, treatment records from January 2010, June 2012, and January 2013 reflect actual left eye visual acuity of at least 20/30. The schedular criteria also provide for evaluations based on incapacitating episodes. An incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. 38 C.F.R. § 4.79, General Rating Formula for Diagnostic Codes 6000 through 6009, Note (2012). In the present appeal, there is no evidence, and the Veteran does not contend, that he has experienced an incapacitating episode and thus further inquiry as to whether an increased rating is warranted based on incapacitating episodes is not required. The rating schedule also provides for evaluations based on visual field impairment. However, notations from the Veteran's treatment records indicate that visual fields of the right eye could not be assessed due to his severely diminished vision. The competence and credibility of the Veteran must also be considered in assigning his statements appropriate weight. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran is competent to give evidence about what he observes or experiences. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). While his statements have been considered, he has not demonstrated the necessary knowledge or expertise to determine which of his symptoms are attributable to his service-connected corneal scar versus those due to nonservice-connected eye conditions. Finally, in evaluating the Veteran's claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. However, as noted above, the evidence in this case specifically distinguishes between manifestations attributed to service-connected versus nonservice-connected eye conditions. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's right eye corneal scar with the established criteria found in the rating schedule for that condition shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. Specifically, visual impairment associated with the condition is expressly contemplated in the rating schedule. The evidence does not reflect that the Veteran's condition results in any symptoms that fall so far outside the rating schedule to render it inadequate. ORDER Service connection for an acquired psychiatric disorder is denied. A compensable rating for a corneal scar of the right eye is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs