Citation Nr: 1315848 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 05-13 364 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and R.M. ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from December 1963 to September 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2003 rating decision on behalf of the Louisville, Kentucky, Regional Office (RO) of the Department of Veterans Affairs (VA). In January 2008, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The issue on appeal at that time was adequately explained to him and the submission of evidence which he may have overlooked and which would be advantageous to his position was suggested. See 38 C.F.R. § 3.103(c) (2012). The issue remaining on appeal was remanded by the Board in February 2010, March 2011, and September 2012. The issue of entitlement to service connection for PTSD was previously denied by the Board in an unappealed February 2010 decision. The Board remanded the issue remaining on appeal for additional development as a result of the United States Court of Appeals for Veterans Claims (hereinafter "the Court") decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board also noted in March 2011 that although the Veteran's representative asserted that service connection was warranted for PTSD there was no indication of a timely appeal from the February 2010 Board decision or evidence of a motion asserting clear and unmistakable error (CUE) in that decision. Thus, the February 2010 decision on the issue of entitlement to service connection for PTSD is final. See 38 C.F.R. § 20.1100 (2012). In its March 2011 remand the Board noted that the issue of reopening a service connection claim for PTSD had been raised by the record and referred adjudication to the Agency of Original Jurisdiction (AOJ). There is no indication of any AOJ action as to this specific matter. The Board does not have jurisdiction over a PTSD service connection claim and it is again referred to the AOJ for appropriate action. FINDING OF FACT The preponderance of the evidence of record shows that the Veteran does not have an acquired psychiatric disorder other than PTSD that had its onset during active service or that is related to any in-service disease, event, or injury CONCLUSION OF LAW An acquired psychiatric disorder other than PTSD was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his case, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). RO letters dated in June 2006 and March 2010 informed the Veteran of all five elements required by 38 C.F.R. § 3.159(b), as stated above. The claim was subsequently readjudicated in June 2010 and February 2013 supplemental statements of the case, thereby curing any timing defect in the notice. Regarding the duty to assist, VA obtained the Veteran's service treatment records, Social Security Administration (SSA) records, and copies of the Veteran's VA treatment records. The Veteran provided copies of private treatment records and statements from his family. The RO also provided the Veteran with VA psychiatric examinations in March 2011 and October 2012. The examination reports obtained contain sufficient information to decide the issue on appeal and further examination is not necessary. See Massey v. Brown, 7 Vet. App. 204 (1994). The Veteran has been afforded a hearing before the undersigned Veterans Law Judge (VLJ) in which he presented oral argument in support of his service connection claim for what was then described as PTSD. 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) (2010) requires that the VLJ or DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the elements that were lacking to substantiate the claim. The VLJ also asked specific questions directed at identifying the criteria for service connection and sought to identify any pertinent evidence not currently associated with the claims, including more details pertaining to the Veteran's alleged stressor. The Veteran also volunteered his treatment history and symptoms since service. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. 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). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the appellant by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the appellant in adjudicating this appeal. II. Service connection Initially it is noted that although the Board has already denied service connection for PTSD in a separate decision, given that some of the evidence related to PTSD is relevant to the evidence pertaining to the acquired psychiatric disorder claim, the Board will address all of the relevant psychiatric evidence in this decision. In this case, the Veteran contends, in essence, that he has an acquired psychiatric disorder other than PTSD as a result of service. In a November 2002 statement in support of the claim the Veteran reported that he could recall being knocked unconscious in Korea, but that he could not recall the specific date. He identified a Sergeant J., First lieutenant E., and Captain M. in response to a form item request for the "names of others involved, killed, wounded, in the event/incident." In a March 2003 statement he reported he was unable to remember most of the events that occurred during his overseas tour of duty. In his December 2003 notice of disagreement he stated he could not recall much about his service overseas, but that he recalled having received stitches to the head at a field hospital. He reported he could not recall the date, location, or circumstances of the injury. He reiterated his claim that he sustained a blow to the head in his barracks that required stitches at a hospital. He again reported he was unable to recall the details. In correspondence dated in April 2004 he stated he sustained an injury involving a cut to the head. The Veteran's daughter and son-in-law provided statements in November 2002 describing symptoms he experienced including crying, isolation, disorientation, paranoia, nightmares, loss of time, loss of short-term memory, flashbacks, self mutilation, and insomnia. It was noted that he had related that he served in Vietnam, but that he had not provided any information about what he had done in Vietnam. S.A., the Veteran's girlfriend, stated that over the past 10 years she had witnessed changes in the Veteran and that he experienced nightmares that he would only identify as related to his past, while he was in the military. In a subsequent statement the Veteran's ex-spouse recalled that the Veteran was always moody and irritable. She stated she had recently learned that this was due to PTSD. At his personal hearing in January 2008 the Veteran testified that he had seen a fellow serviceman in Korea who was killed due to a severe head trauma while on top of a cable car crossing a river. He stated he did not know the serviceman and that he could not recall the location or an approximate date of the incident. It was asserted by his service representative that it was during his first duty assignment in Korea. He also testified that he had fallen onto a footlocker while he was drunk and received stitches to the head, but that he could not recall the location or an approximate date of this incident. He was unable to identify whether the fall occurred before or after the cable car incident in Korea. In an August 2008 statement the Veteran's former spouse reported problems she had experienced with the Veteran during their 20 year marriage. In a July 2012 post-remand brief the Veteran's representative asserted that the Veteran witnessed several distressing events during service in Korea, that he had mental problems since that time, and that he drank to alleviate his mental stress over the years. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that proof of direct service connection may entail proof that exposure during service caused the malady that appeared many years later); Cosman v. Principi, 3 Vet. App. 503, 505 (1992) (holding that service connection can still be established even when a Veteran did not have a particular condition diagnosed during service or for many years thereafter). In order to establish service connection, the evidence must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. Alternatively, under 38 C.F.R. § 3.303(b), the second and third Shedden/Caluza elements can be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). The U.S. Court of Appeals for the Federal Circuit has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing inservice incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). In this case other than psychoses, an acquired psychiatric disorder is not considered a chronic disability under 38 C.F.R. § 3.309(a). Therefore, service connection for an acquired psychiatric disorder other than psychoses can only be established by showing inservice incurrence or aggravation or that the post-service diagnosis is related to service. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. Symptoms, and not treatment, are the essence of any evidence of continuity of symptomatology. Savage, 10 Vet. App. at 496. The third Barr/Savage element is not equivalent to the third Shedden/Caluza element, as requiring medical nexus evidence under 38 C.F.R. § 3.303(b) would nullify that regulation. Id. at 497. However, it does not follow that any present disability is necessarily related to any demonstrated continuous symptomatology. Id. Therefore, in Savage, the Court held that competent evidence is required to demonstrate a relationship between the continuous symptoms and the presently diagnosed disability. Id. (explaining that "medical evidence is required to demonstrate such a relationship unless such a relationship is one to which a layperson's observation is competent"). 38 U.S.C.A. § 1154(a) requires VA to give "due consideration" to "all pertinent medical and lay evidence" when evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Generally, the Board should determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). "Sometimes 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." Jandreau, 492 F.3d at 1377, n4. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lastly, a layperson may also be competent to testify to the manifestations of a chronic condition during service or a presumptive period or to continuity of symptomatology. Hickson, 12 Vet. App. at 253. Certain chronic disabilities, including psychoses, may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Turning now to the facts of this case, service treatment records are negative for complaint, treatment, or diagnosis of a psychiatric disorder. A March 1965 report noted sutures were removed from the right supraorbital area. There was no indication as to the nature of the initial injury. The Veteran's September 1965 separation examination revealed a normal clinical neurologic and normal clinical psychiatric evaluation. Service records show he had over one year and three months of service in Korea. He received no wounds as a result of enemy action and there are no awards or medals indicative of combat. There is no evidence of service in the Republic of Vietnam. Based on these findings there is no evidence of direct inservice incurrence or aggravation of an acquired psychiatric disorder under 38 C.F.R. § 3.303(a). The Veteran's reported stressor of witnessing an individual that had been killed also cannot be corroborated, as he did not provide enough identifying information to conduct a search of the event. Also, given that the Veteran's psychiatric disorder has not been identified as a psychoses or other chronic disorder listed under 38 C.F.R. § 3.309(a), service connection would not be warranted under 38 C.F.R. § 3.303(b) based on continued symptomatology since service. Thus, the only avenue for service connection is under 38 C.F.R. § 3.303(d) for a disease diagnosed after service when all evidence establishes that the disease was incurred in service. Social Security Administration (SSA) records show the Veteran was found to be disabled beginning in September 1995. A primary disability diagnosis of chronic obstructive pulmonary disease and a secondary diagnosis of cardiomegaly were provided. The associated records did not include report of a psychiatric disorder. An October 1996 VA treatment record notes that the Veteran had an appointment at the Huntington VAMC for PTSD, but there is no corresponding record reflecting this treatment. A July 1997 VA treatment record shows the Veteran's complaints of depression, anxiety, and memory problems. An April 1998 VA treatment record notes the Veteran had been having night sweats several times a week for the last year. In May 1998, a VA pulmonary treatment record also notes that during a pulmonary function test the Veteran's eyes rolled back and he passed out for a few seconds. It was noted that he had a history of hypertension and was on several antihypertensive medications with syncopal episode and that possible impressions were drug-induced orthostatic hypotension; cardiac arrhythmia/rule-out myocardial infarction; vasovagal syncope; carotid sinus syncope; and transient ischemic attack. An August 1998 VA treatment records also notes the Veteran's complaining of nightmares for the past few years. In August 2001, the Veteran was admitted into the Mental Health Unit at a VA hospital for suicidal ideation and depression. It was noted that his friends he had been involved with working to sell coal had cheated him out of money. He was given an Axis I diagnosis of adjustment disorder with depressed mood. He also was assessed as having major depression on a separate August 2001 treatment record. On neurological evaluation in September 2001, he admitted to having left-sided numbness for five years and a tingling sensation of his right upper extremity when waking. He also presented with a history of "black-out" spells for a long time, some of which associated with coughing. He admitted to smoking marijuana one to two times per week and a history of alcohol abuse, but noted that the infrequent blackouts were not associated with drinking. He also had episodes of numbness usually on the left and growing ataxia. The impression was cough syncope; and it was noted that the other spells might be seizure activity or cardiac syncope. An electroencephalogram (EEG) in September 2001 was abnormal because of focal slowing activity noted independently in both temporal regions, consistent with focal cerebral dysfunction in those areas. A later September 2001 VA outpatient mental health record notes the Veteran could not remember why he was in the hospital or what happened to put him there. He stated that he was doing much better but was very nervous. He reported that he had nightmares about five to six times per night about his military service in Korea. In November 2001, a VA mental health outpatient treatment record notes complaints of anxiety and mild depression. He also complained of frightening nightmares and some loose imagery related to military combat. He was assessed as having recurrent major depressive disorder in December 2001. He reported dreams of someone with a bayonet chasing him. He denied any exposure to combat during his military service, but stated that his memory had not been the same since service. The Veteran continued to receive treatment for major depressive disorder and anxiety disorder through 2002. His main complaint was nightmares. His complaints of "blackouts" also were revisited on a neurology record in April 2002. The impression was possible cough syncope. It was noted that an MRI would be ordered to exclude seizures but this was doubtful as the cause. (There are no further MRI studies of record.) The pattern of sensory deficit was suspicious for polyneuropathy due to diabetes and the examiner also agreed with the appropriate extent of cardiac work-up to exclude potential causes of cardiogenic syncope. In May 2003, he was assessed as having major depressive disorder. He said he was upset because soldiers are heroes and he was spit on and that he was dreaming a lot about people being disfigured. He slept about four hours a night. VA treatment records include diagnoses of PTSD without indication of a specific stressor. The reports show the Veteran denied combat experiences. A January 2002 report noted he had a past diagnosis of prolonged PTSD, but that there was no clear specification of a traumatic stressor in the previous notes to warrant such a diagnosis. The examiner stated that the diagnosis was possibly provided because the Veteran was a Korean veteran and had military imagery in nightmares. It was further noted, however, that in discussing his military experiences the Veteran denied any significant combat trauma and related his fearful imagery of dreams to basic training exercises. In the absence of a stressor meeting DSM-IV criteria the diagnoses of depression and anxiety disorder were found to be more appropriate. VA treatment records dated in April 2006 noted the Veteran reported that his memory had not been the same since he was discharged from service and that he had fallen in his barracks requiring eight to ten stitches. The examiner provided an Axis II diagnosis of rule out a personality disorder secondary to head injury. A November 2006 VA examination provided diagnoses including major depressive disorder and generalized anxiety disorder without opinion as to etiology. It was further noted that while the Veteran did not meet the criteria for a diagnosis of PTSD there was no information suggesting that his psychopathology occurred prior to military service. An April 2007 statement noted that VA records showed the Veteran was treated for major depressive disorder from September 2001 and that the diagnosis was changed to PTSD in August 2003. An undated private psychological assessment report based upon testing in February and March 2007 found the Veteran met the criteria for PTSD by being exposed to traumatic circumstances, re-experiencing the trauma, avoiding stimuli associated with the trauma, and increased arousal not present before his military experiences. It was noted that the Veteran attributed his difficulties to his involvement with the military, but that his case was complicated because the specifics of his experiences could not be determined due to problems with memory and possibly due to some resistance to talk about them. It was also noted that he remembered being in a jeep when he was scheduled to return home and that the driver wrecked, but that he could not remember any specifics after that to include having gotten on the airplane. The examiner also noted he reported experiencing flashbacks of people being killed. The report indicated that the Veteran stated he was unable to remember his time in service, but that he stated it was "the most scary experience [he] had in life." It was noted that the Veteran appeared to meet the criteria for PTSD; he also described symptoms of major depression and cannabis abuse. The examiner further noted that it was very possible he was beginning to experience dementia, due to age, possibly in part to drug use, and his psychological problems. Based upon the evidence of record, the Board found that an additional medical examination was required prior to appellate review and remanded this matter. In its March 2011 remand the Board's instructions included a request that the Veteran be scheduled for a VA examination for an opinion as to whether there is at least a 50 percent probability or greater (at least as likely as not) that he has an acquired psychiatric disorder other than PTSD as a result of active service, to include as a result of head trauma. It was specifically noted that in statements in support of his claim the Veteran claimed he had been knocked unconscious in service, but that he could not recall the details of this injury. In correspondence dated in April 2004 he stated he sustained an injury involving a cut to the head. Service treatment records show he received sutures for a cut to the right supraorbital area in March 1965. A September 1965 separation examination revealed normal clinical neurologic and psychiatric evaluations. VA treatment records dated in April 2006 also noted the Veteran reported that his memory had not been the same since he was discharged from service and that he had fallen in his barracks requiring eight to ten stitches. The examiner provided an Axis II diagnosis of rule out a personality disorder secondary to head injury. A November 2006 VA examination report included diagnoses of major depressive disorder and generalized anxiety disorder and noted there was no information suggesting the Veteran's psychopathology occurred prior to military service. Thereafter, the Veteran underwent a VA examination in March 2011. The examiner noted that the Veteran reported onset of depressive symptoms 20 years ago. He did not attribute the depressive symptoms to military service and stated that he could not say what caused it but that it first happened 20 years ago. The Axis I diagnosis was cannabis abuse, depressive disorder, and rule-out cannabis-induced mood disorder. The examiner found that the Veteran's psychiatric disorder was not related to service because his reported depressive symptoms started 25 years after his discharge; he did not attribute depressive symptoms to service when he was hospitalized with suicidal ideation in 2001, but rather to workplace stressors; and he regularly used marijuana, which complicated his psychiatric picture. Although the examiner noted the claims file had been reviewed, the provided report included no discussion as to the demonstrated injury to the right supraorbital area in March 1965 nor as to the findings of the April 2006 and November 2006 VA examiners. It was further asserted by the Veteran's representative in a July 2012 post-remand brief that the March 2011 examiner's reliance upon "an alleged comment" by the Veteran during the examination that his depressive symptoms first started 20 years after service required additional explanation as the statement was inconsistent with the other evidence of record. Therefore, the Board remanded the claim again for a supplemental opinion to address the deficiencies of the previous opinion. In October 2012 a supplemental opinion was provided by the same VA psychologist. Once again it was noted that the claims file was reviewed. The examiner determined that the Veteran's claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner indicated that at no time during the course of the appeal was there evidence of an acquired psychiatric disorder other than PTSD as a result of active service, to include as a result of head trauma. The rationale was the same as before: that the Veteran reported that his depressive symptoms had onset at least 25 years after his discharge from military service. As such, current depressive symptoms were not related to service. The examiner also noted that the Veteran did not attribute depressive symptoms to service. When he was hospitalized for depression with suicidal ideation in 2001, he attributed his symptoms to workplace stressors. In addition it was noted that the Veteran regularly used marijuana, which likely had a significant, negative impact on his mood. The examiner indicated that the Veteran would need to be drug free for at least six months before a determination could be made that his mental health symptoms were not related to his substance abuse, which was standard in the substance abuse field. With regard to the right supraorbital injury documented in March 1965, the examiner noted that there was no evidence of any psychiatric disturbance that resulted from that injury. The examiner commented that the request for the examination referenced documentation in April 2006 but did not specify what exactly was "inconsistent" about the findings. The examiner indicated that she was assuming that the request was referring to the Veteran's self-report in April 2006 that his memory "has not been the same since he was discharged from the military." The examiner commented that the 2006 examiner did not diagnose any cognitive disorder, but did offer a "rule out" diagnosis of personality disorder secondary to head injury. The examiner determined that a "rule out" was not a formal diagnosis, and a personality disorder diagnosis was not supported or documented in the note. That diagnosis also appeared to be inconsistent with his current presentation, as there was no evidence of this right now. Finally the examiner commented that the Board's request indicates that she should comment on a November 2006 examination, but she was unable to find any VA record dated in November 2006. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's claimed acquired psychiatric disorder other than PTSD is not related to any event in service. In making this determination, the Board finds it significant that the only evidence of record indicating a possible nexus between any current psychiatric disorder other than PTSD and his military service are the Veteran's assertions. The Board acknowledges that the Veteran is competent to report that he has continued to experience memory and mental health problems since service. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Veteran is also competent to report that he was suffered a head injury in service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled, or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It is within the Veteran's realm of personal knowledge whether he suffered a head injury in service and has continued to experience memory and mental health problems since military service. The service treatment records document sutures being removed from the right orbital area in 1965; therefore it is reasonable to deduce that the Veteran did, in fact, have a head injury in service. However, the Board finds that the Veteran's statements are not credible with respect to the onset and continuity of his memory loss and mental health symptoms. He has had somewhat inconsistent statements regarding the details of the events in service. The Veteran testified in January 2008 that he tripped over a footlocker while drunk in the barracks and suffered a head injury during his military service; but in his December 2003 notice of disagreement he stated he recalled having received stitches to the head at a field hospital but could not recall the date, location, or circumstances of the injury. He also never reported psychiatric problems that he related to service for many years after service. Although an October 1996 VA treatment record notes that the Veteran had an appointment at the Huntington VAMC for PTSD, there is no corresponding record reflecting this treatment. The July 1997 VA treatment record showing the Veteran's complaints of depression, anxiety, and memory problems does not indicate that the Veteran related these symptoms to his service. The Veteran also had complaints of nightmares and night sweats in 1998, but still did not relate his symptoms to his military service. The first hospitalization for psychiatric problems was in August 2001. Although the Veteran eventually complained of nightmares related to Korea in September 2001, he initially presented to the hospital with complaints that his co-workers had cheated him out of money. He stated in 2001 that his memory had not been the same since service, but did not first complain of memory problems until 1997, which was 32 years after service. Also, on his March 2011 VA examination report, he indicated that the onset of depressive symptoms occurred approximately 20 years ago (i.e., in 1991, 26 years after his military discharge). In addition it is worth mentioning that the Veteran has a long history of cannabis abuse, which the examiner in October 2012 determined complicated any clear psychiatric diagnosis for the Veteran. Therefore, with respect to the onset of experiencing memory problems and mental health problems, the probative value of the Veteran's lay assertions is diminished and the Board cannot rely on his statements. Even if the Veteran's statements regarding the onset of the memory loss and mental health problems were credible, it does not follow that any present acquired psychiatric disorder other than PTSD is necessarily related to any demonstrated continuous symptomatology. While the Veteran is competent to state that he has suffered from symptomatology since service, he is not competent to determine the underlying cause of the symptoms, i.e., major depression, anxiety disorder, etc. Moreover, as noted, to the extent that the Veteran is asserting entitlement to service connection based on continued symptomatology since service, service connection would not be warranted on this basis, as his claim is not based on a chronic condition listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that his current acquired psychiatric disorder other than PTSD is related to his military service; however, there is no competent medical evidence or opinion to corroborate these contentions. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The Veteran's opinions are insufficient to provide the requisite nexus between an in-service event or injury and any current disability because, as a lay person, he is not competent to establish a medical etiology merely by his own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512, 520 (2004); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (holding that a layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, his statements regarding the etiology of any psychiatric disabilities are merely speculation as to a possible cause as he is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to medical causation. The Board also finds it significant that a VA examiner in March 2011 and October 2012 found that after reviewing the claims file and pertinent medical history that the Veteran's current psychiatric disorder was not related to any head injury in service or other event in service. The rationale for the opinion was that when the Veteran first was hospitalized for a psychiatric disorder in 2001 he initially complained of work-related problems; the Veteran reported onset of symptoms approximately 20 years ago; and there was no evidence of psychiatric disturbance associated with his injury to the right supraorbital area in service. The examiner also considered the Veteran's claim in 2006 of experiencing memory loss in service but noted that no cognitive disorder was noted at that time. The probative value of the October 2012 examiner's opinion is high as the examiner was fully informed of the Veteran's medical history, provided a fully articulated rationale, and the opinion was supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-04 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board had also asked the VA examiner to comment on the November 2006 VA examiner's comment that there was no evidence of psychiatric problems prior to service. The examiner in October 2012 indicated that she could not locate the November 2006 record; and the Board determines that this is not fatal to the claim. The November 2006 finding merely shows that the Veteran did not have psychiatric problems prior to service, but in no way indicates that the current symptoms are related to his military service. Therefore, the fact that the October 2012 examiner did not consider the November 2006 report in her opinion does not undermine the probative value of the October 2012 opinion. With respect to the Veteran's statement that he had experienced psychiatric problems since service, on examination in 2011 he noted that he had only started to experience depressive symptoms 20 years prior and could not determine the cause. The Veteran's representative asserted in a July 2012 post-remand brief that the Veteran's testimony should be given greater weight than his statements on examination in March 2011. However, the Board does not see any reason to give a higher probative value to statements during a hearing than to statements made during a medical examination. On the contrary, the inconsistency of the Veteran's statements only serves to undermine the probative value of his lay statements. With respect to the Veteran's claims of memory loss since service and any possible neurological involvement from the Veteran's reported head injury in service, as noted, given that he first reported memory problems in 1997, his more recent statements in 2001 and 2006 of experiencing memory problems since service are not credible. His neurological evaluation in service was normal. In 2001 the Veteran reported having a history of "blackouts" and had an abnormal EEG, but there was never a clear diagnosis given to determine the cause of the Veteran's symptoms. At no time were these symptoms related to the Veteran's military service including his head injury in service; it was noted that they could have pulmonary, hypertension medication, or cardiac involvement, or that the symptoms even could be related to his diabetes or a possible stroke or seizures. In 2007, a private psychological assessment also shows the Veteran could have dementia related to age, cannabis abuse, and in part, due to psychological symptoms; but these symptoms were not related to the Veteran's military service, specifically his reported head injury in service. In short, none of the post-service medical evidence relates the Veteran's current psychiatric diagnoses other than PTSD to service; so service connection under 38 C.F.R. § 3.303(d) is not warranted. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's current psychiatric disorder other than PTSD had its onset during active service or is related to any in-service disease, event, or injury. See 38 U.S.C.A. §§ 1110, 1131. Accordingly, the Board finds that the criteria for service connection for an acquired psychiatric disorder other than PTSD are not met and the Veteran's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). ORDER Entitlement to service connection for an acquired psychiatric disorder other than PTSD is denied. ____________________________________________ S.L. KENNEDY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs