Citation Nr: 1315670 Decision Date: 05/13/13 Archive Date: 05/15/13 DOCKET NO. 02-08 844 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for an acquired psychiatric disorder including posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Lisa Ann Lee, Attorney ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from May 1969 to May 1971. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2001 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2003, the Board remanded the appeal for further development. In March 2006, the Board denied service connection for an acquired psychiatric disorder including PTSD. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In May 2007, the Court vacated the decision and remanded the appeal for compliance with the instructions in a Joint Motion for Remand. In September 2007, the Board remanded the appeal to the RO for further development. A review of the Virtual VA paperless claims processing system contains additional relevant evidence that has been considered. FINDING OF FACT The weight of credible and probative lay and medical evidence is that the Veteran does not have PTSD and that his diagnosed depression, possible bipolar disorder, and heroin and cocaine abuse, in early remission, are not caused or aggravated by combat or any other aspect of active duty service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder including PTSD are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137, 1154 (West 2002); 38 C.F.R. §§ 3.301, 3.303, 3.304, 3.307, 3,309, 3.384, 4.125 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION 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 must notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Where complete notice is not timely accomplished, such error may 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); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The RO received the Veteran's claim for service connection for PTSD, insomnia, and depression in May 2000, prior to the enactment of the notice requirements in November 2000. Although an adequate notice was not provided prior to the initial decision on the claim, notices were provided in June 2004 and November 2006 that met the requirements followed by an opportunity to respond and readjudication of the claim in supplemental statements of the case in May 2005 and August 2012. Moreover, the Veteran has submitted statements and argument in support of the claim that demonstrate actual knowledge of the criteria for service connection, the types of evidence that will be considered, and the Veteran's and VA's responsibility to obtain relevant evidence. The duty to notify is satisfied when claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board concludes that the Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities in obtaining relevant evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and relevant VA and private medical records are in the file. The Veteran has also not indicated that he is in receipt of Social Security Administration disability benefits. VA has made reasonable efforts to obtain federal correctional institution records identified by the Veteran. The duty to assist also includes providing a medical examination or obtaining a medical opinion when it is necessary to make a decision on a claim. The Veteran underwent VA examinations in July 2004 and April 2012, and the results have been included in the claims file. The examinations involved review of the claims file by qualified examiners, a thorough examination of the Veteran, and opinions supported by sufficient rationale. Therefore, the Board finds that the examinations are adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. The Veteran served in U.S. Army infantry units including combat service in the Republic of Vietnam from October 1969 to October 1970. The Veteran was awarded the Bronze Star Medal for meritorious service, the Air Medal, and the Combat Infantryman's Badge. He contends that his multiple acquired psychiatric disorders including PTSD were caused by traumatic events in combat. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service-connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). 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 service. See 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Absent a diagnosis of a chronic disease as defined in 38 C.F.R. § 3.309(a), service connection may not be awarded based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). "Psychosis" is defined to include schizoaffective disorder, schizophrenia, and substance-induced psychotic disorder, but not anxiety, depressive, or posttraumatic stress disorders. 38 C.F.R. § 3.384. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV)); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy," as established by recognized military combat citations or other official records. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, the veteran's lay statements alone may establish occurrence of the claimed in-service stressor, in the absence of clear and convincing evidence to the contrary, as long as the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); see Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The RO received the Veteran's claims for service connection for insomnia, depression, and PTSD in May 2000. Service treatment records are silent for any symptoms, diagnoses, or treatment for a psychiatric disorder or for substance abuse. A Report of Transfer or Discharge (DD-214) received by the RO in May 1975 showed the dates of the Veteran's active service and combat awards. The Report did not specify the service location Vietnam, although the dates and combat action infer service in Vietnam. The RO received the complete service personnel records in May 2004 that confirmed combat service. In statements in June 2000, June 2004 and April 2011, the Veteran described his participation in small arms firefights with the enemy. In one encounter, the Veteran reported killing two enemy soldiers at close range. The Veteran noted that while in service during and after his combat tour of duty, he began abusing drugs and alcohol. As there is service record evidence supporting the Veteran's combat service in Vietnam, the Board concludes that the Veteran's description of the combat events is credible and sufficient to show that the events actually occurred. VA education records and employment reports from the Veteran showed that the Veteran was granted education benefits in the early 1970s and worked as a local police officer for six years. The Veteran reported that he was convicted of conspiracy involving the distribution of illegal drugs and was incarcerated in a federal correction institution from 1989 to 1999. The Veteran submitted an August 1989 pre-sentencing Assessment for Aftercare prepared by a U.S. Probation Officer Drug Treatment Specialist and a consulting mental health specialist. The probation officer noted that the Veteran had worked for four years as an automobile salesman and had two previous drug-related arrests. The officer noted the Veteran's reports of experiencing depression since returning from Vietnam and that he began using heroin and cocaine starting in 1980 as a self treatment for insomnia and depression and had two previous drug-related arrests. The officer noted that the Veteran had received VA hospital treatment two months earlier but for only two hours. The officer did not note any particular events in service but determined that the Veteran's problems were PTSD and drug dependency and recommended that the Veteran serve his sentence in a federal medical center followed by supervised release with psychiatric treatment. Correspondence was received from the Veteran in the 1990s with an address of the Federal Medical Center in Fort Worth Texas. (This facility now provides treatment services only for women inmates). The earliest treatment records in the claims file start with VA outpatient clinic treatment in Puerto Rico in December 1999 that mention symptoms of depression and a history of substance abuse. In December 2000, a clinician noted the Veteran's reports of sleep disturbances, intolerance of other people, bad humor, and irritability. The clinician diagnosed depression and prescribed medication. In April 2001, an attending VA psychiatrist noted the same symptoms and social isolation and recurrent thoughts of his combat experiences including the close quarters combat. The psychiatrist diagnosed depression and possible PTSD. In November 2000, a VA physician noted a review of the claims file including the DD-214. The physician incorrectly noted that the service record did not explicitly show service in Vietnam. The physician did not discuss events in service but noted the Veteran's reports of drug use in service, changes in personality after service, and VA diagnoses of depression. The physician diagnosed substance abuse disorder, reportedly in remission, alcohol abuse, adjustment reaction with anxious mood, and antisocial personality disorder but not PTSD. In a May 2001 statement, the Veteran's former spouse noted that their relationship changed after the Veteran returned from Vietnam. She reported that the Veteran became temperamental and aggressive and that the trauma of war caused him to make mistakes that lead to time in prison. The former spouse did not mention the Veteran's admitted drug abuse that started in service. In October 2001, the RO denied service connection for insomnia, depression, and PTSD. The RO acknowledged that the combat events were verified but that the current diagnoses were associated with substance abuse and not military service. The Veteran expressed timely disagreement and perfected a substantive appeal, contending that he was experiencing PTSD. In October 2003, the Board remanded the appeal to obtain a complete file of service personnel records and another mental health examination. In February through June 2003, the attending VA psychiatrist again noted the same symptoms as in 2001. The psychiatrist noted sleep interruption but did not note any events in service or symptoms related to those events and diagnosed chronic schizophrenia. In July 2004, a VA physician noted a review of the claims file and accurately summarized the 1989 probation officer report and VA mental health treatment since 2000 that showed diagnoses of depression, adjustment disorder, and schizophrenia. The physician noted that the Veteran's last visit to the VA clinic was in June 2003. The Veteran reported irritability, insomnia, depressed mood, and anxiety with frequent relapses of daily heroin and cocaine abuse. Notably, the Veteran did not report intrusive thoughts, nightmares, or avoidance behavior related to the experiences in Vietnam. The Veteran described several combat situations but was not anxious, distressed or depressed when describing them, did not exhibit avoidance behavior, nor did he report intense fear, helplessness, or horror at the time of the events, an unusual response considering the danger inherent in a close quarters firefight. The psychiatrist diagnosed depressive disorder and heroin and cocaine dependence but concluded that the Veteran did not meet the diagnostic criteria for PTSD. The psychiatrist concluded that the depressive disorder was not caused by events in service because the Veteran did not begin treatment until 2000 after release from incarceration. The psychiatrist did not explain why the 1989 probation officer's report was not relevant, credible, or probative. In a single brief outpatient encounter in May 2005, the attending psychiatrist noted that the Veteran had sleeping disturbances, nightmares, and recurrent thoughts of his experiences in Vietnam that were exacerbated by current war news. The Veteran reported continued social isolation and intolerance of contact with others. The physician diagnosed bipolar disorder and PTSD but did not repeat the original diagnosis of schizophrenia. In June 2005, an internal medicine physician noted a history of diagnoses of PTSD and bipolar disorder since 2005 and residual schizophrenia since 2003 but performed no mental health examination. The physician noted the Veteran's reports of anxiety, restlessness, irritability and difficulty sleeping but primarily addressed an unrelated physical disorder. In March 2006, the Board denied service connection for depression, schizophrenia, bipolar disorder, and PTSD. The Board summarized the service and post service evidence noted above except for the May 2005 encounter and concluded that the weight of credible evidence was that the Veteran did not have PTSD and that the depression, schizophrenia, and bipolar disorder were first diagnosed many years after service and was not caused or aggravated by events in service. In May 2007, the Court vacated the decision because the Board did not discuss why it rejected the May 2005 psychiatrist's conclusion. While the appeal was pending before the Court, in March 2006 the Veteran traveled to a VA facility in New York City to seek treatment for an unrelated physical disorder. While at the VA facility, the Veteran underwent a positive screening test for PTSD and was referred to the mental health clinic. In June 2006, a VA psychologist examined the Veteran who described the same events in service but with more detail. The Veteran reported experiencing anxiety and depression since the completion of active duty, that the most significant symptoms were nightmares and difficulty controlling anger, and that he self-medicated his symptoms with drugs and alcohol until quitting 17 years earlier. The Veteran reported working as a policeman and landscaper but did not report his decade of incarceration. The Veteran reported that his VA mental health treatment beginning in 1999 was the only treatment he had received and did not report any treatment while incarcerated. On examination, the psychiatrist noted depressed mood and anxiety associated with recollections of the combat events and diagnosed PTSD and depressive disorder with possible bipolar and substance abuse disorders. The Veteran received medication and group therapy over the next year with improvement in the frequency and intensity of the intrusive thoughts and nightmares. In August 2007, the Veteran's then-current representative presented argument that the previous VA examinations were not adequate and that records from the federal institution were necessary to assist the Veteran in his claim for service connection for PTSD. The representative did not contend that the Veteran had multiple disorders but rather that PTSD manifested with many associated symptoms including anxiety and depression. In September 2007, the Board remanded the appeal for the RO to review new evidence submitted by the Veteran, to make reasonable efforts to obtain records of the Veteran's medical care at the federal corrections institution, and to obtain an additional VA psychiatric examination. The Board did not specify a particular level of examiner qualification. On multiple occasions from December 2010 to February 2012, the RO requested records from the federal institution and from the U.S. Bureau of Prisons Office of General Counsel. No records were found. The Board concludes that the RO made multiple reasonable requests and that further efforts seeking these records would be futile. The Veteran returned to Puerto Rico VA clinics and resumed outpatient mental health treatment. In May 2007, a clinician noted the Veteran's reports of continued anxiety, restlessness, irritability, social isolation, and distrust of others. The clinician diagnosed bipolar disorder. In November 2007 and again in January 2008, the Veteran was admitted to a VA hospital for symptoms of depression and for detoxification following a divorce and increased substance abuse. At some time in 2008, the Veteran moved to Chicago and received outpatient VA mental health treatment for the same symptoms with diagnoses of PTSD, bipolar disorder with manic episodes, and schizophrenia. He moved back to Puerto Rico briefly in approximately August 2008. Records of VA treatment in Puerto Rico show continued treatment for the same symptoms. Clinicians noted previous diagnoses of PTSD, bipolar disorder, schizophrenia, and depression but the treatment was entirely for detoxification from continued substance abuse. The Veteran returned to Chicago the same month. Clinicians referred to the events in service, chronic substance abuse, domestic conflicts, and unemployment as factors in the continuation of variously diagnosed disorders. In November 2009, a clinician diagnosed only opiod dependence. The Veteran often underwent standard clinic PTSD screenings with variable results. For example, in January 2010, the Veteran denied any nightmares, hypervigilance, avoidance behaviors or social isolation. In April 2011, the Veteran submitted a statement from a neighbor attesting to the severity of his psychiatric symptoms but with no comments on the origins of the disorder. The same month, the Veteran submitted statements reaffirming his belief that his insomnia, depression, and other symptoms of PTSD arose from the combat events and that he was not aware he could seek VA treatment until after release from incarceration in 1999. The Veteran continued to receive regular VA outpatient and occasional inpatient mental health treatment from January 2010 to July 2012. In July 2010, the attending psychiatrist noted that the Veteran was receiving inpatient treatment for depression and suicidal ideation in the context of out of control heroin and cocaine use. PTSD was listed in the history and as an admission diagnosis but not as a working diagnosis later in August with no current symptoms associated with events in service. It is not clear how long the Veteran was hospitalized. In October 2010, an attending psychiatrist noted that the current stressors were living alone and ongoing addition. The psychiatrist noted that the Veteran was not clear but claims to have intrusive thoughts and flashbacks about Vietnam. The Veteran checked himself in to a VA hospital again in August 2011 for treatment for heroin and cocaine abuse. Several clinical notes mention the Veteran's reports of multiple PTSD symptoms such as nightmares, flashbacks, hypervigilance, intrusive thoughts, and insomnia that he experienced weekly since returning from Vietnam. The attending psychiatrist noted that the symptoms were difficult to discern whether they are due to intoxication or withdrawal effects of heroin. In one summary, the attending psychiatrist diagnosed heroin and cocaine dependence and suspected PTSD although the symptoms should be assessed after the Veteran discontinued substance abuse. In another summary a few days later, the psychiatrist listed PTSD as a diagnosis with comments limited to treatment for substance abuse. In November 2011, a psychiatrist noted the Veteran's reports of continued substance abuse, depression, suicidal ideations, and hallucinations. The Veteran reported combat experiences but also reported that he enjoyed war movies and was irritable regarding not receiving VA compensation. The psychiatrist continued to diagnose depression exacerbated by substance abuse, rule out PTSD because it was mentioned in the history. In a December 2011 discharge summary, two VA psychiatrists listed "history of Post-traumatic stress disorder" as one of the final diagnoses. In a note describing the prognosis, the psychiatrists determined that it was poor given the chronic significant addiction, PTSD, and questionable follow-up. In June 2012, the Veteran was again admitted for inpatient treatment. Another attending psychiatrist noted, "The patient has a h/o PTSD but his clinical presentation and course are complicated by substance abuse vs. dependence as well as by poor treatment adherence. Urine toxicology is positive for benzos, opiates and cocaine." Nevertheless, the psychiatrist listed PTSD along with various substance dependence disorders. In April 2012, a VA psychologist noted a review of the claims file and the electronic VA treatment and examination records. The examination report was entered by the Assistant Chief of Staff for Ambulatory Care at a VA Medical Center but was annotated that the examination report was reviewed and approved by the examiner, identified as a doctoral level psychologist and assistant professor of clinical psychology with clinical and teaching experience in forensic topics. The psychologist accurately summarized the Veteran's social, military, and occupational history from the record and from the Veteran's oral reports. The psychologist noted the Veteran's combat experiences without challenge and noted that the experiences met the diagnostic criteria for traumatic events. The Veteran reported that after returning from Vietnam for duty in Germany he experienced a "fair" adjustment but had problems dealing with a lack of "action" as he had experienced in combat. The Veteran worked as a law enforcement officer for 6 years after service but resigned because of reportedly unfair treatment associated with multiple weapons firings in the course of his duties. The Veteran reported that he was married four times for short periods and fathered several children but that the marriages dissolved because of arguments. The Veteran reported his incarceration from 1989 to 1999 for conspiracy to sell drugs and fought frequently in prison. He reported that he received treatment for substance abuse while incarcerated. After release, the Veteran worked only briefly but had a strong relationship with his mother until her death and currently resided with friends who provided support. He reported that he had not used drugs for the previous six months. On examination, the psychologist noted symptoms of recurrent nightmares of combat events and a depressed mood. Absent were avoidance of activities, cues, or people or persistent symptoms of arousal such as irritability, hypervigilance, loss of concentration, or exaggerated startle response. The Veteran reported that he enjoyed watching war movies, read books about Vietnam, and followed the news about current hostilities. There was no affective response, detachment, or emotional numbing. The psychologist also noted symptoms associated with hypomanic episodes including staying awake for two three days, agitation, and restlessness. However, the Veteran reported that these episodes were followed by sleep periods of six to 12 hours per day. The Veteran reported memory lapses such as forgetting that he left a cooking stove on. In the examination report and in an addendum one day later, the psychologist concluded that the Veteran did not meet the diagnostic criteria for PTSD. The psychologist acknowledged that symptoms of hypervigilance, startle response, nightmares, and flashbacks were noted in the past. However, the psychologist also noted multiple negative PTSD clinical screenings and concluded that the symptoms were in the context of on-going substance abuse and were most likely related to that abuse. The psychologist declined to diagnose PTSD because of the absence of symptoms associated with avoidance and arousal criteria as noted in her clinical examination. The psychologist did diagnose depressive disorder and possible bipolar and substance abuse disorders. The psychologist assessed the substance abuse as in early remission and concluded that the depression was less likely related to military service because of the onset more than 30 years after service and because other factors such as the symptoms and consequences of chronic drug use were more likely the cause. The psychologist noted, "Vet's drug dependence causes the most significant impairments based on the number of admissions to rehab as well as legal, relationship, and occupational problems resulting from his drug use. Depression causes less impairment." In August 2012, the Veteran's representative submitted argument in support of the appeal. The representative concluded that the April 2012 psychiatric examination was not performed by a qualified examiner, was inadequate, and warranted no probative value. The representative noted that the Assistant Chief of Staff was an internal medicine specialist and not a psychiatrist or doctoral-level psychologist as specified by the Board in the July 2007 remand. Further, the examiner placed weight on an earlier VA examination that did note symptoms of hypervigilance, sleep problems, and exaggerated startle response which the examiner failed to note in her examination report. The examiner also failed to consider the assessment by the federal probation officers in 1989. The representative cited many excerpts from clinical reports from 2000 to 2011, highlighting notations of common PTSD symptoms and diagnoses of PTSD. The representative contended that adequate consideration had not been given to the entire history, that the Veteran had been diagnosed with PTSD, and that depression was clearly linked to military service. As a preliminary matter, the Board concludes that there has been substantial compliance with the instructions in its September 2007 remand. The RO made multiple attempts to obtain Federal records of treatment from the U.S. Bureau of Prisons without success. Moreover, the Veteran later reported to clinicians that he received treatment for substance abuse but not for other psychiatric disorders until after his release. The Veteran was provided an opportunity to identify any other private mental health care providers or examiners and did not identify additional sources of treatment. Contrary to the contentions of the representative, the Veteran was provided a VA examination in April 2012 that was adequate. The examiner was a doctoral-level psychologist who reviewed the entire record including the 1989 probation officer's report. The examination accurately summarized the history of events in service, symptoms since service, and previous diagnoses and treatment. The Board concludes that the Veteran is both competent and credible to report the traumatic events that he experienced in combat and the nature and severity of his symptoms thereafter. The Veteran's spouse and neighbors are also competent and credible in describing the Veteran's behavior after service and at the present time. Lay evidence is competent when a condition can be identified by a layperson. See 38 C.F.R. §§ 3.159(a)(1) and(2) (defining competent medical and lay evidence) and 3.307(b) (as to chronicity and continuity of symptoms lay evidence should describe material and relevant facts observed and not merely conclusions based upon opinion). Lay evidence may, in some circumstances, establish a medical diagnosis, causation or etiology, i.e., when a layperson (1) is competent to identify the medical condition, (2) is reporting a contemporaneous medical diagnosis, or (3) describes symptoms at the time which supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir. 2009) (overruling the broad holdings in Buchanan v. Nicholson, 451 F.3d 1331 (Fed.Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (2007) that competent medical evidence is required when the determinative issues if either medical etiology or a medical diagnosis); see also King v. Shinseki, 700 F.3d 1399 Fed.Cir. 2012); 2012 WL 6029502 (C.A.Fed.) (confirming that Davidson, Id., overruled the broad holdings noted above in Buchanan, Id., and Jandreau, Id.). In this case, the lay observations of behavior and symptoms warrant probative weight but a diagnosis and etiology of a psychiatric disorder, particularly PTSD, is a complex matter requiring medical training and experience. The 1989 probation officer and all VA medical providers and examiners are competent and credible because they have at least some training in the evaluation of behaviors and were able to interview or examine the Veteran. All based their observations and opinions on a substantially correct history except the November 2000 VA examiner who did not acknowledge the Veteran's combat service. The Board assigns low probative weight to his observations and will further discuss the probative weight to be assigned to the other sources of evidence below. The Board concludes that service connection for an acquired psychiatric disorder including PTSD is not warranted because the weight of credible and probative lay and medical evidence is that the Veteran's mental health symptoms do not meet the criteria for PTSD but rather are best diagnosed as depression and manifestations and residuals of chronic substance abuse not caused or aggravated by events in service. The Veteran has been diagnosed with an acquired psychiatric disorder. The disorder did not manifest in service as the service records are silent for any symptoms, treatment, or diagnoses. Following his combat service in Vietnam, the Veteran satisfactorily completed his obligated service in Germany and later acknowledged to an examiner that he made a fair adjustment and only had problems with a lack of action. He acknowledged the start of drug abuse in service and that the abuse continued after service. The Veteran successfully completed VA funded education and worked as a law enforcement officer and salesman for several years and did not seek treatment for symptoms at this time. He reportedly received some unfair disciplinary action, and his spouse noted increased aggressiveness and temperament. Several marriages failed because of arguments. The Veteran was convicted of conspiracy to sell drugs. Absent a medical opinion to the contrary, the Board is unable to conclude that argumentative behavior alone is necessarily a manifestation of a psychiatric disorder and that substance abuse is necessarily a form of self-medication as contended by the Veteran. The Veteran's psychiatric disorder has been variously diagnosed as depression, PTSD, bipolar disorder, schizophrenia, and most frequently and consistently, substance abuse. The Board considered the 1989 probation officer's pre-sentencing screening. The Veteran submitted only what appears to be the last page of a report. The Board assigns some limited probative weight to the observations and opinions in the partial report. Although the officer identifies himself as a drug treatment specialist assisted by a mental health specialist but their medical qualifications for diagnosis and recommendations for treatment of mental illness are unknown. The officer noted the Veteran's report of depression since service and the use of prescription medications from a primary care physician. The officer also noted that the Veteran supplemented the medication with abuse of heroin and cocaine for more than 10 years. The officer noted the Veteran's belief that it was self medication but made no assessment of his own. The officer concludes without testing that the Veteran's primary problem is PTSD although his specialty is in substance abuse treatment. The officer did not discuss symptoms other than depression, specific events in service, or any specific components of a diagnosis of PTSD. Therefore, the Board assigns some weight to the conclusion that the Veteran has abused drugs and required substance abuse treatment in prison. The Board assigns very low weight to a reference to PTSD as the officer does not appear to be qualified to offer that diagnosis nor did he explain the rationale for this conclusion. In addition, the Veteran later acknowledged to examiners that he was treated for substance abuse in prison but did not receive other forms of psychiatric care. The Board assigns limited probative weight to the ex-spouse's observations of temperamental and aggressive behavior. Although her observations are competent and credible, she is not competent to determine the cause. Several qualified medical examiners noted that these symptoms are also associated with chronic substance abuse. The Veteran acknowledged that the abuse started in service. The Board assigns low probative weight to the neighbor's observations that describe only then current symptoms, long after service and after years of substance abuse. The Board assigns some probative weight to the observations and diagnoses in the VA irregular outpatient treatment records from 1999 to 2005. The attending psychiatrist and other clinicians noted symptoms of sleep disturbance, irritability, depression, and occasionally recurrent thoughts of combat. An attending psychiatrist diagnosed possible PTSD in 2001 and PTSD in 2005 with little discussion. The attending psychiatrist also offered several diagnoses including bipolar disorder and schizophrenia. The Board assigns greater probative weight to the report of a VA examination in July 2004. This psychiatrist reviewed the entire file and considered the 1989 probation officer's report and the outpatient VA treatment to date, but not the May 2005 diagnosis. The psychiatrist noted several symptoms consistent with PTSD but several other symptoms that were absent, particularly symptoms associated with avoidance behaviors. He noted that the Veteran did not appear to be anxious or distressed in describing his combat experiences nor did he report that they caused unusual horror or fear at the time. The psychiatrist performed a detailed examination and concluded with an explanation that the Veteran did not meet the criteria for a diagnosis of PTSD. Although he inaccurately concluded that depression and drug abuse only manifested after release from incarceration, his conclusion that these disorders were not caused by combat events is reasonably supported by the first onset of the symptoms after many years of successful functioning as a police officer. The Board places probative weight on the combined observations and diagnoses by multiple outpatient and inpatient mental health clinicians from 2006 to 2012. All of these treatment encounters were noted to be primarily repeated courses of detoxification from heroin and cocaine dependence. Clinicians offered variable diagnoses of bipolar disorder, schizophrenia, depression, and PTSD in addition to drug abuse. However, on some occasions, primary care screenings for PTSD were negative. The Board assigns greater probative weight to the comment of an attending psychiatrist in August 2011who explained that the symptoms were difficult to discern because many are also a consequence of intoxication and withdrawal. Other clinicians noted PTSD only as possible, rule-out, or a historical diagnosis. Treatment during this period of time was exclusively related to substance abuse. There was no evidence of counseling or psychotherapy dealing directly with PTSD. There were also no observations or opinions to suggest that the drug abuse was a form of self-medication for PTSD or disorders caused by traumatic events in service. Finally, the Board places greatest probative weight on the observations and opinions of the VA psychologist in April 2012. Notably, this evidence warrants greater weight in part because examination was performed after six months of sobriety from drug abuse. This examiner has significant training and experience in mental health forensics. This examiner reviewed the entire case history, performed a detailed clinical examination, and provided explanations to support the conclusions. The psychologist acknowledged the earlier diagnoses including PTSD. Consistent with the opinion in 2004, the psychologist noted that although the Veteran had some symptoms associated with PTSD, he also did not display the avoidance symptoms that are necessary to meet the diagnostic criteria. Consistent with the observations in August 2011, the psychologist explained that the symptoms are a consequence of prolonged drug abuse. The psychologist diagnosed depression, possible bipolar disorder, and substance abuse in early remission but found that these disorders manifested after service, were not related to combat events, and were consequences of drug abuse. The examiner inaccurately noted that depression began 30 years after service. However, this does not degrade her opinion since the earliest notation of depression was in the 1989 parole officer's report, still many years after service. The Board considered whether service connection for substance abuse is warranted on the basis of the Veteran's contention that the abuse was a form of self-medication. Absent other factors, the intentional use of substances for intoxicating effects is misconduct and not subject to service connection. 38 C.F.R. § 3.301 (d). The Veteran underwent years of treatment for substance abuse and none of the attending clinicians or VA examiners concluded that drug abuse was self-medication. The parole officer noted this contention in his report but did not indicate concurrence. Except for the portion of the November 2000 VA treatment report that did not consider combat, the Board has not rejected any lay or medical evidence as not credible or inadequate. The Board acknowledges that the Veteran performed distinguished and difficult combat service. Service in a combat zone is stressful to some degree to all who are there, whatever their duties or experiences. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board acknowledges the Veteran's briefs that list many occasions when the term PTSD was noted in a record. The Board considered all the evidence and assigned relative probative weight as warranted by the qualifications of the observers, the context and timing of symptoms and treatment, the nature and circumstances of the treatment or evaluation encounters, and the degree of detail and analysis in the diagnoses and opinions. The great weight of credible lay and medical evidence is that the Veteran does not have PTSD and that his depression, substance abuse, and possible bipolar disorders first manifested after service and are not caused or aggravated by events in combat or any other aspect of active duty service. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for an acquired psychiatric disorder including posttraumatic stress disorder (PTSD) is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs