Citation Nr: 1316154 Decision Date: 05/16/13 Archive Date: 05/29/13 DOCKET NO. 10-01 011 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to service connection for a variously diagnosed psychiatric disability, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a variously diagnosed skin disability, to include as secondary to Agent Orange exposure. 3. Entitlement to a rating in excess of 30 percent for duodenal ulcer with hiatal hernia. 4. Entitlement to a compensable rating for bilateral hearing loss. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1958 to January 1961. These matters are before the Board of Veterans' Appeals (Board) on appeal from February 2004 and May 2009 rating decisions by the Cheyenne, Wyoming. In March 2006 the Board remanded the matters regarding gastrointestinal disability, bilateral hearing loss, and TDIU, and in August 2011 remanded the matters regarding psychiatric and skin disabilities. The matters of the ratings for a duodenal ulcer with hiatal hernia and bilateral hearing loss, and entitlement to a TDIU rating, are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. The Veteran does not have a diagnosis of PTSD in accordance with DSM-IV based on a corroborated stressor event in service; a chronic psychiatric disability was not manifested in service; a psychosis was not manifested within one year after the Veteran's separation from service; and no diagnosed psychiatric disability is shown to be related to his service. 2. A chronic skin disability was not manifested in service, and any current chronic skin disability is not shown to be related to the Veteran's service. CONCLUSIONS OF LAW 1. Service connection for a psychiatric disability, to include PTSD, is not warranted. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. Service connection for a variously diagnosed skin disability is not warranted. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Regarding the claims seeking service connection, the Veteran was advised of VA's duties to notify and assist in the development of the claims prior to their initial adjudication. March 2008, March 2009, and August 2012 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. These letters also informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in these matters was less than adequate. The Veteran's service treatment records (STRs) and service personnel records are associated with his claims file, and pertinent postservice treatment records have been secured. The RO arranged for a VA skin examination in September 2011. As will be discussed in greater detail below, the Board finds this examination to be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) Whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain chronic diseases were manifested during an applicable postservice presumptive period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the U.S. Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA psychiatric examination is not necessary, as there is no evidence suggesting there may be a nexus between any current psychiatric disability (first diagnosed many years after service) and the Veteran's active duty service. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system) with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also 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. To establish service connection for a disability, a Veteran must show the existence of the disability; incurrence or aggravation of a disease or injury in service; and a causal relationship between the present disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence 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). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Psychiatric disability Certain chronic disabilities (to include psychosis) may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time following discharge from active duty (one year for psychosis). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Where the veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, then the veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997). Service department records must support, and not contradict, the claimant's testimony regarding noncombat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). On July 12, 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. Specifically, the final rule amends 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 adding a new paragraph (f)(3) that states: If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire; including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The Veteran's STRs are silent for any complaints, findings, treatments, or diagnoses of a psychiatric disability. On January 1961 service separation examination, psychiatric findings were not evaluated (noted as "NE"). On April 1961 VA examination, no significant abnormalities were noted on psychiatric evaluation. After separation from service in 1961, the first medical evidence of the Veteran having mental health difficulties was in 1994 (33 years after separation). On May 1994 treatment for obesity control, the Veteran reported having anxiety over many family matters. In May 1994 the Veteran was hospitalized for anxiety; he was noted to be a recovering alcoholic who had some family problems; the diagnostic impressions included history of substance abuse, alcohol dependency not presently active, dysthymic disorder, anxiety and depression. Zoloft and Vistaril were prescribed for anxiety. On August 1994 treatment, the Veteran was noted to have had dysthymia diagnosed; the treating psychologist stated that the Veteran did not appear depressed; he appeared to convert his anxiety into physical problems. The diagnostic impression was undifferentiated somatoform disorder. It was noted that the Veteran was preoccupied with his physical symptoms, and it would be difficult to get at his underlying psychological issues. On November 1994 treatment, the Veteran showed increased anxiety over the deaths of two brothers. On November 1998 treatment, the Veteran was noted to have a history of anxiety and problems sleeping. On July 2000 VA treatment, the Veteran was noted to have anxiety/depression. On February 2008 VA treatment, the Veteran was referred from the Emergency Department for the evaluation of depressional symptomatology the previous month, at which time he was diagnosed with major depressive disorder and sleep dysfunction; at that time he also suffered from significant chronic grief secondary to the loss of his wife. On treatment, the impressions included major depressive disorder; possible PTSD symptomatology, secondary to events in service, in particular an incident in which he was directly involved in associated with fire; and chronic grief syndrome due to the loss of his wife. On May 2008 VA treatment, the Veteran reported two non-combat trauma events in service. He stated that he had bottled up his feelings regarding these events for several years, which had much to do with his excessive drinking. He stated that he never told his parents, his wife, or anyone else. He reported that his wife asked him to leave their bed because he was shouting and fighting in his sleep; he reported that he would go outside and cry where nobody would see him. He became tearful speaking about his wife who had died (after which he began drinking again). Following a mental status examination, the diagnoses included PTSD from non-combat trauma during military service, major depressive disorder without psychosis, and bereavement. The diagnoses were the same on March 2009 VA treatment. On July 2009 VA treatment, the Veteran reported new stressor information. Specifically he reported that he had stumbled upon two other sailors who were engaging in anal intercourse while serving on active duty. He reported that he was "jumped" by another sailor, whom he "put out of commission". He reported that he was awakened that night by the click of the hammer of a gun by one of the sailor's buddies who was going to avenge the beating. He reported that the Master at Arms was checking on him and turned on the lights before the gun went off. He reported that the sound of that click woke him up at night for many years, but that had not happened for some time. The assessments included PTSD from non-combat trauma during military service, major depressive disorder without psychosis that was remitting, and bereavement due to the loss of his wife. The Veteran has reported two stressor events that allegedly occurred during his service. He contends that he was very near a large gun that blew up on his ship. He also contends that he was jumped by another sailor whom he cut in self defense, and he was then threatened with a gun in his face by a friend of that sailor. See May 2008 VA treatment report. A March 2009 VA memorandum concluded that the information required to verify the stressful events described by the Veteran was insufficient to send to the Joint Services Records Research Center (JSRRC) and/or insufficient to research for a Navy record. A formal finding on the unavailability of verifiable stressor information was made. VA treatment records now show a diagnosis of PTSD based on these two reported (yet uncorroborated) stressor events, as well as diagnoses of major depressive disorder. Regarding PTSD, the Veteran does not contend, and the evidence does not show, that he engaged in combat with the enemy. Consequently, his alleged stressors for a diagnosis of PTSD must be corroborated by credible supporting evidence. However, his noncombat stressors are not corroborated, and he has not received a diagnosis of PTSD that is based on a stressor that is corroborated. The Board observes that the relaxed evidentiary standards of the revised 38 C.F.R. § 3.304(f)(3) do not apply in this case, given the circumstances of the Veteran's service and the nature of his allegations. The Veteran's accounts of the two cited stressors have been determined to be either uncorroborated or incapable of corroboration based on information available. He has indicated, in essence, that there is no corroboration for his accounts. The Board finds that many of the Veteran's statements regarding stressors, which stand alone, are simply not credible. "Credibility can be genuinely evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, official plausibility of the testimony, and the consistency of the witness's testimony". The Veteran's accounts of stressors have been inconsistent, and are compensation-driven and self-serving. See Pond v. West, 12 Vet. App. 341 (1999). They cannot serve as a valid underlying basis for a diagnosis of PTSD. As noted above, some of the treatment records do show diagnoses of PTSD. However, such diagnoses are based on the Veteran's accounts of stressor events that are unsupported and deemed not credible. A medical opinion premised upon an unsubstantiated account is of no probative value and does not serve to verify the occurrences described. See Swann v. Brown, 5 Vet. App. 229, 233 (1993); see also Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996) (an opinion by a mental health professional based on a postservice examination of the Veteran cannot be used to establish the occurrence of a stressor). Therefore, these diagnoses lack probative value. In summary, the record does not show that the Veteran engaged in combat with the enemy, there is no credible supporting evidence of his alleged non-combat stressor events, and there is no valid diagnosis of PTSD based upon any verified stressor. The threshold legal requirements for establishing service connection for PTSD are not met, service connection for such disability is not warranted. As the record shows diagnoses of psychiatric disabilities other than PTSD, the analysis proceeds to whether any other psychiatric disability diagnosed may be service connected. A chronic acquired psychiatric disability was not noted in service or clinically noted post-service prior to 1994, and service connection for a psychiatric disability on the basis that such disability became manifest in service and persisted is not warranted. As a psychosis is not shown to have been manifested in the first postservice year, the chronic disease presumptive provisions of 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309 do not apply. Finally, there is no competent evidence that relates the Veteran's psychiatric diagnoses other than PTSD to his service. Regarding the Veteran's own opinion that he has a psychiatric disability that is due to his service, he is a layperson (with no demonstrated or alleged expertise in determining a medical nexus); does not offer any supporting medical opinion or medical treatise evidence; does not cite to any supporting factual data; and does not offer any explanation of rationale for his opinion (other than the rejected-as not-credible accounts of stressor events in service). Therefore, his opinion in this matter has no probative value. The Board recognizes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). That is, competent medical evidence is not necessarily required where the determinative issue in a case involves medical causation or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. Sept. 14, 2009), citing Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this case, the Veteran is not providing statements related to the diagnosis of a simple disorder or about symptomatology but is instead rendering an opinion to the effect that he has a mental disability that is related to service. A mental disability is not a condition capable of lay diagnosis, nor is it the type of condition that can be causally related to military service without medical expertise (in the absence of service onset and continuity). Davidson, 581 F.3d 1313; Buchanan, 451 F.3d 1331; Jandreau, 492 F.3d 1372. The etiology of a psychiatric disease is a matter of medical complexity. The Board concludes that, although the Veteran is competent to report symptoms he may have experienced in service and after service, his statements as to the diagnosis and etiology of any current psychiatric disability do not constitute probative evidence in the matter. Accordingly, the preponderance of the evidence is against the Veteran's claim of service connection for a variously diagnosed psychiatric disability, and the appeal in the matter must be denied. Skin disability Certain diseases may be service connected on a presumptive basis as due to herbicide (Agent Orange) exposure if manifested in a Veteran who served in the Republic of Vietnam during the Vietnam Era, due to presumptive exposure to certain herbicide agents. 38 U.S.C.A. § 1116. Those diseases are listed in 38 C.F.R. § 3.309(e); chloracne or other acneform disease consistent with chloracne is listed. However, as the Board noted in the August 2011 remand, the record does not show that the Veteran served in an area where certain herbicides, including Agent Orange, were used; he has not specified any details of his alleged exposure to herbicides. Therefore, the presumptive provisions of 38 U.S.C.A. § 1116 do not apply, and service connection on a presumptive basis for the skin disability as due to Agent Orange exposure is not warranted. The Veteran's STRs reflect that he was treated for heat rash in service, in July and August 1958. There were no further complaints, findings, treatment, or diagnosis regarding the skin during service. On January 1961 service separation examination, the Veteran's skin was normal on clinical evaluation. On April 1961 VA examination, no significant abnormalities were noted on skin evaluation. On April 1970 private treatment, the Veteran reported no history of any abnormal skin rashes or pigmentations. On July 1978 VA hospitalization, the Veteran reported having had symptoms of neurodermatitis with skin eruption when he is nervous. Seborrheic dermatitis was noted on physical examination. On April 1979 VA treatment, the Veteran was noted to have many excoriated areas on the anterior lateral thigh areas and on the upper arms and shoulder areas; he was noted to have a previous diagnosis of neurodermatitis. On April 1980 VA treatment, innumerable, discreet, circumscribed, maculopapular, desquamating, pigmented lesions were noted over the skin of the trunk and extremities; they appeared chronic and excoriated. The impressions included neurodermatitis. On August 1980 treatment, the Veteran was noted to have dermatitis, "? due to insecticide". He reported that he had had this problem before, and it was thought to be neurodermatitis. On February 1981 VA examination pursuant to a service connection claim for ulcers, the Veteran reported having sores that break out over his body. On physical examination, he was noted to have multiple small (approximately 5 millimeters) circular lesions over the shoulders, upper arms, and thighs, which gave the impression of a neurodermatitis of mild degree. On July 1982 VA treatment, the assessments included neurodermatitis. On August 1982 treatment, the Veteran complained of a skin rash for "years". The assessment was probable neurodermatitis. On May 1987 VA hospitalization, it was noted that a punch biopsy of the Veteran's skin showed minimal perikeratosis with focal spongiosis with elongation of the pegs on the right hip; the changes were nonspecific but compatible with neurodermatitis. On November 1990 treatment, the Veteran had an apparent lipoma over the triceps muscle on the right arm, which he believed had been present for several years. He reported that he tried to have it removed, but the surgeon had indicated that it was unrelated to his nerve problems in his hands and the discomfort associated with removing it would be out of proportion to any potential benefit. On January 1991 treatment, it was noted that a "skin rash continues, now on toe". On April 1994 treatment, the Veteran complained of [rash] breaking out on his right hand for 3 to 4 days, his dorsum, his left leg for 6 months, and his right upper thigh following a cat scratch 2 weeks earlier. He believed the breaking out was caused by exposure to herbicides and/or cleaning solutions. He reported a history of battling a recurring pruritic rash for 18 years (or since approximately 1976). The diagnostic impression was solar dermatitis. On May 1994 treatment, the Veteran was noted to have a history of neurodermatitis since 1973. On July 1994 treatment, the Veteran stated that he was allergic to herbicides. He was noted to have neurodermatitis on his hands, arms, right thigh, and left leg. On October 1994 treatment, the Veteran had been dealing with red blotches on his arms, legs, and abdomen for 6 months; the assessment was allergic dermatitis with cellulitis. In December 1995, the previously noted right shoulder lipoma was excised. On December 1997 treatment, the Veteran was evaluated for a chronic eruption on his hands, feet, and penis. It was noted that this had been biopsied as neurodermatitis. Evaluation of his skin showed multiple evidence of prior neurotic excoriations with scars on the dorsal forearms, as well as an eczematous dermatitis, which he picked at. His feet showed evidence of keratoderma and erosion secondary to scratching, and primary tinea pedis. On October 1998 private treatment, the Veteran was noted to have a multiple year history of an excoriated eruption of the extremities and trunk. He readily admitted to the manipulation of the lesions, reporting in detail his need to pick at these areas. The assessments included prurigo simplex and prurigo nodularis. The treating physician noted that prurigo is a common condition in which patients develop papular excoriated lesions from chronic manipulation of the skin, of which they may or may not be aware, and stress is often an associated factor. On November 1998 treatment, the Veteran was noted to have neurodermatitis that flared up when he gets nervous or anxious. On April 1999 VA skin examination, it was noted that the Veteran was diagnosed with a "heat rash" in 1958 while in service, and he was treated with quinine powder. He reported that it came and went throughout his career and it was always treated as a heat rash. He did not recall having any rash at the time of his discharge from service. He stated that the rash continued to be an on and off problem and had been diagnosed as psoriasis, eczema, and neurodermatitis. Following a 1981 biopsy, the diagnosis was neurodermatitis. Following a 1998 biopsy, the diagnosis was excoriations. He reported that the rash had progressively worsened in the previous five years. The impression was neurodermatitis. On May 1999 VA Agent Orange examination, the Veteran reported that he was stationed on a ship during the Vietnam era, although he was not stationed in Vietnam. He reported that he had a three day period when he was asked to wear a gas mask while onboard the ship; allegedly there was a helicopter maneuver spraying on a nearby island, although it was not Vietnam. He reported that one time he stood guard in a barracks that held several drums, although he did not receive any type of exposure to the substance stored in the drums. He reported no overt exposure to Agent Orange. The examiner noted that in service the Veteran had "heat rash" diagnosed, which he reported had never completely gone away; his postservice diagnoses included neurodermatitis, psoriasis and eczema. On physical examination, the Veteran's skin had multiple lesions, some of which were open and some of which had scabbed; there were multiple scars to his skin from a rash that had been ongoing for several years. The assessments included psoriasis, eczema, and neurodermatitis. The examiner had difficulty finding a relationship between the fact that it was not believed the Veteran was exposed to Agent Orange as he did not serve in Vietnam and was not in Vietnam, and he had no direct exposure to Agent Orange to his knowledge. A January 2000 rating decision denied the Veteran service connection for neurodermatitis, psoriasis, and eczema. A January 2001 rating decision granted the Veteran compensation under 38 U.S.C.A. § 1151 for second degree chemical burns of the lower extremities, upper extremities, and abdomen. On May 2002 VA treatment, the Veteran reported that he could not be in sunlight for very long or his skin would turn pink and erupt in sores; he believed this was from chemical burns from VA skin doctors. On March 2004 VA examination, the Veteran was noted to be service connected for second degree burns and scars present primarily on the arms and legs, with some lesions over the lower abdomen. He reported continuing to have an episodic itching and burning sensation and pain in both legs, primarily in the area of the scarring; sun or cold exposure would also make the skin red and cause pain. His treatment consisted of Triamcinolone ointment and Clotrimazole with Cortisone ointment. The diagnoses following physical examination included second degree chemical burns with current macular dermatitis. On January 2005 VA examination, it was noted that the Veteran was given a prescription for urea cream in 1997, although an error had resulted in him receiving instructions to apply the cream all over his body, when it was supposed to be applied only to his feet. He used the cream for approximately two years and sustained chemical burns to his arms, legs, and torso. He got a secondary bacterial infection in the areas of the burns, treated with antibiotics. He reported having chronic intermittent problems with his skin since that time, with waxing and waning courses of itching, burning, and pain in the areas of the chemical burns. Following a physical examination, the assessment was extensive scarring from chemical burns, along with current extensive infected lesions. On May 2007 VA treatment, the Veteran was noted to have a many year history of skin inflammation. He presented with an exacerbation of his skin condition. He reported being told in the past that it was related to contact dermatitis from herbicides. It was noted that an April 1990 punch biopsy indicated psoriaform dermatitis most consistent with pityriasis rubra pilaris. The assessment was that the differential diagnosis of the Veteran's condition is broad; the clinical appearance appeared consistent with atopic dermatitis, and other possibilities included pityriasis rubra pilaris, contact dermatitis, psoriasis, and drug reaction. On July 2007 VA examination, the Veteran reported that he first noted skin lesions in 1997 after use of a lotion on his skin that caused burns to the skin. He noted a continued rash with burning and itching on a daily basis. Following a physical examination, the assessment was diffuse lesions with residual scars. On October 2009 VA treatment, the Veteran reported that he had been tested for allergies the previous month and had been shown as allergic to wool alcohols and all kinds of rubber, in addition to several chemicals. On January 2010 VA examination, the examiner noted that the Veteran's initial skin problem while he was in the military was diagnosed as heat rash. The Veteran believed he should have been diagnosed with contact dermatitis caused by contact with various chemical substances and the use of rubber gloves. He reported that he sustained second degree burns in 1998 after a prescription that had been written for a urea compound was re-written with directions for use all over the body rather than just on the feet; he had had continuous skin problems since 1998. The Veteran reported that over the years, the skin problem had been exacerbated by the use of other lotions and creams. He reported that the lesions were currently being aggravated by the use of a CPAP mask and oxygen tubing. He reported burning and itching sensations all over his body which he had experienced daily since 1998. The diagnoses included acute and chronic contact dermatitis involving most of the body with secondary infection involving the face and ears, and multiple allergies. The examiner noted that the skin did not have the appearance of thermal or chemical burn, as by definition second degree burns generally heal without scarring. Additional VA and non-VA treatment records through June 2012 include assessments of neurodermatitis, eczema, cellulitis, tinea pedis, psoriasis, and puritis, with no opinions regarding etiology or whether such disability is related to the Veteran's service. On September 2011 VA skin examination, the Veteran's diagnosis was neurodermatitis. He reported that he developed a rash in service, which the STRs show was diagnosed as a heat rash. The Veteran contended that he may have been exposed to Agent Orange. The examiner noted that the available records show he was not exposed to Agent Orange. The Veteran reported that after service he developed another skin rash that was diagnosed as neurodermatitis; he repeatedly stated that this is the condition which had been diagnosed and treated. His treatment had consisted of constant or near-constant antihistamines. Following a physical examination, the examiner noted the Veteran's reports that he has always been a nervous person with a "short fuse". He described many incidents in his life that were "nerve racking". The examiner noted that the diagnosed condition of neurodermatitis causes patients to have a sense of persistent itching, as a result of which they scratch the areas that itch but this does not relieve the symptoms and often makes it worse. The patients then enter a cycle of persistent itching and scratching which leads to excoriation and breakdown of the skin. The examiner stated that the common treatment for this condition is topical steroids to decrease the irritation and sense of itching as well as oral antihistamines to decrease the sense of itching; as the patients often scratch at night while sleeping, they are advised to wear gloves while sleeping to avoid severely scratching the skin. The examiner noted that the records reflect this had been advised for the Veteran, although he admitted he was no longer following the advice. He had been treated with topical steroids and oral antihistamines. The VA examiner opined that the Veteran's condition is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the diagnosis of neurodermatitis had been reached after serial exams documented in the medical records, and had also been confirmed by a punch biopsy. The Veteran is aware of the diagnosis and repeatedly affirmed that this is his condition on examination. The examiner again noted that this is a condition that presents as a sense of persistent itching, and patients will constantly scratch at and excoriate their skin. The examiner noted the Veteran's diagnosis of a heat rash while serving onboard a ship in the southern Pacific region, noting that there is no documentation he was diagnosed with neurodermatitis at that time. The examiner noted the Veteran's contention that he was exposed to Agent Orange, although the claims file documents seem to refute that claim; the examiner stated that neurodermatitis is not associated with Agent Orange exposure. The examiner noted that the Veteran's neurodermatitis was diagnosed after he left military service, and he was not diagnosed with neurodermatitis while serving in the military. The examiner opined that the Veteran's current skin condition is not associated with exposure to toxins and is not related to military service. A chronic skin disability is not shown to have been manifested during service; the Veteran's STRs are silent for any diagnosis thereof; his heat rash in service was acute, and resolved without residuals. Consequently, service connection for a variously diagnosed skin disability on the basis that such disability became manifest in service and persisted is not warranted. The analysis turns to whether a chronic skin disability may somehow otherwise be related to the Veteran's service. In the absence of manifestation in service and postservice continuity, the etiology of an insidious process such as a skin disability is a complex medical question that requires medical knowledge/training. See Jandreau, 492 F. 3d at 1377. The VA opinions in the record are against the Veteran's claim; cumulatively they are adequate for rating purposes (as they reflect familiarity with the record and include explanation of rationale that is consistent with factual data). The September 2011 examiner opined that the record provided no basis for relating a skin disability to service. The Veteran is a layperson and lacks the training/expertise to offer a probative opinion in a medical matter that is beyond the capability of lay observation. He does not cite to supporting medical opinion or medical literature. His explanation of his perceived rationale is inconsistent with/contradicted by factual data (e.g., there is no evidence he was exposed to Agent Orange; his service predated the Vietnam Era) and inconsistent with the state of medical knowledge). A VA examiner points out that what was manifested in service does not reflect a diagnosis of neurodermatitis (which the Veteran now acknowledges is the proper diagnosis for his current skin disability). In summary, the preponderance of the evidence is against a finding that any chronic skin disability is related to a disease or injury in service in service. Accordingly, the Board concludes that the preponderance of the evidence is against this claim, and that the appeal in the matter must be denied. ORDER Service connection for a psychiatric disability, to include PTSD, is denied. Service connection for a variously diagnosed skin disability, to include as due to herbicide exposure, is denied. REMAND On March 2006 remand, the Board found a March 2004 VA examination for the Veteran's gastrointestinal disability was inadequate, as the evaluation was very cursory and did not provide sufficient clinical information to properly adjudicate the claim for a rating in excess of 30 percent for duodenal ulcer with hiatal hernia. Additionally, the Board noted that the Veteran had been afforded a VA audiological evaluation in January 2004, but the results reported on that occasion were reported in very general estimates in terms of a range of both decibels and Hertz levels. The Board found the report to lack the specific results necessary to evaluate the extent of hearing loss under the provisions of 38 C.F.R. § 4.85. The Board remanded both matters to afford the Veteran new VA examinations to ascertain the current severity of the disabilities. The matter regarding TDIU was remanded as inextricably intertwined with the increased rating claims. A thorough review of the Veteran's claims file and Virtual VA found that these remand instructions were never addressed. It is well-established in caselaw that when remand orders of the Board are not complied with, the Board itself errs in failing to insure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). Here, the RO has readjudicated the matters on the merits in a July 2011 supplemental statement of the case, suggesting that development pursuant to the Board's March 2006 remand has been acceptable and complete. The actions previously sought by the Board are necessary for a proper adjudication of the Veteran's appeal. As there has not been substantial compliance with the remand orders, the matters must be remanded once again for compliance. Accordingly, the case is REMANDED for the following action: 1. The RO should arrange for an audiological evaluation of the Veteran (with audiometry) to determine the current severity of his bilateral hearing loss. The Veteran's claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination. The examiner must be provided a copy of the applicable criteria for rating the disability at issue. All clinical findings should be reported in detail. The examiner should explain the rationale for all opinions (and if the examination findings conflict with findings noted in treatment records reconcile the discrepancies). The report of examination must include the examiner's discussion of the impact the hearing loss has/would be expected to have on the Veteran's everyday and occupational functioning. 2. The RO should also arrange for the Veteran to be afforded an appropriate examination to assess the current severity of his duodenal ulcer with hiatal hernia. The Veteran's claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination. The examiner must be provided a copy of the applicable criteria for rating the disability at issue. All clinical findings should be reported in detail. The examiner should explain the rationale for all opinions (and if the examination findings conflict with findings noted in treatment records reconcile the discrepancies). 3. The RO should then review the record and readjudicate the Veteran's claims (TDIU in light of the findings pertaining to the increased ratings claims). If any remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs