Citation Nr: 1316608 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 10-03 690 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. What evaluation is warranted for posttraumatic stress disorder (PTSD) with adjustment disorder and depression from November 20, 2009 to June 3, 2011? 2. What evaluation is warranted for posttraumatic stress disorder (PTSD) with adjustment disorder and depression from June 4, 2011? 3. Entitlement to service connection for residuals of a neck injury. 4. Entitlement to service connection for nerve damage of the left arm and hand, to include secondary to a neck injury. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from September 1954 to December 1957. These matters initially came before the Board of Veterans' Appeals' (Board) on appeal from November 2009 and June 2010 decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. In November 2009, the RO denied entitlement to service connection for neck injury and nerve damage left arm/left hand. In June 2010, the RO granted entitlement to service connection for PTSD and assigned a 30 percent rating, effective November 20, 2009. The Veteran timely appealed the initial rating assigned and the RO in June 2011 increased the rating to 50 percent, also effective November 20, 2009, thus creating the issue as listed on the title page. In December 2011, the Board denied the claim of entitlement to a higher initial rating for PTSD and remanded the service connection claims to the RO, via the Appeals Management Center (AMC), for additional development. In an August 2012 Order, the United States Court of Appeals for Veterans Claims (the Court) granted a Joint Motion by counsel for the Veteran and VA to vacate the Board decision and remand the PTSD claim to the Board. In the interim, the RO/AMC performed the additional development as instructed with regard to the service connection claims. Consequently, all three claims are now back before the Board. A videoconference hearing was held before the undersigned Veterans Law Judge in October 2011. At that time, the record was held open for 60 days so that additional evidence could be submitted. To date, such evidence has not been received. The question what rating is warranted for posttraumatic stress disorder with adjustment disorder and depression since June 4, 2011, is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Resolving reasonable doubt in the appellant's favor, his posttraumatic stress disorder was manifested by no more than occupational and social impairment, with deficiencies in most areas between November 20, 2009 and June 3, 2011. 2. Cervical spine disability and radiculopathy of the left arm and hand are unrelated to in-service neck injury. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for a rating of 70 percent for posttraumatic stress disorder, with an adjustment disorder and depression, were met between November 20, 2009 and June 3, 2011. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. Cervical spine disability and radiculopathy of the left arm and hand were not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). 3. Radiculopathy of the left arm and hand is not proximately due to, the result of, or aggravated by, a service connected disease or injury. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159 (2012). As service connection, an initial rating, and an effective date have been assigned for posttraumatic stress disorder, with adjustment disorder and depression, the notice requirements of 38 U.S.C.A. § 5103(a) have been met. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Consequently, discussion of VA's compliance with VCAA notice requirements as they relate to this claim would serve no useful purpose. With regard to the service connection claims, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in January 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. These claims were most recently readjudicated in September 2012. VA also fulfilled its duty to assist. In its December 2011 remand, the Board instructed the RO/AMC to contact the Veteran regarding treatment at a Naval Hospital and request that he identify all treatment dates. The Veteran did not respond. The Board also instructed that the RO/AMC attempt to obtain records from a VA Medical Center where the Veteran stated he was treated as well as from the Naval Hospital and to document its efforts and explain them to the Veteran. March and September 2012 reports of contact document the efforts that the RO/AMC made to obtain these records and the negative responses provided by the relevant institutions. January and August 2012 letters to the Veteran explained the RO/AMC's actions that were taken in connection with these records and indicated that he could send the records himself or notify the RO/AMC of these records. The RO issued a September 2012 formal findings as to the unavailability of these records. As the custodians of the records indicated that there were no records at their institutions as had been indicated by the Veteran, and the appellant did not provide additional identifying information as requested, the RO/AMC complied with its duty to assist and with the Board's December 2011 remand instructions. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street"); 38 C.F.R. §§ 3.159(c)(1)(i), (c)(2)(i) (requiring claimant to cooperate fully with VA's efforts to obtain federal and non-federal records, including providing identifying information); 38 C.F.R. § 3.159(c)(2) (VA may end efforts to obtain Federal records if further efforts would be futile). In September 2009, VA made a formal finding that the Veteran's service treatment records, other than the separation examination report and report of medical history, were unavailable and that they may have been destroyed by a fire at the National Personnel Records Center in 1973. When a Veteran's service treatment records are unavailable through no fault of his own, VA's duties to assist, to provide reasons and bases for its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule, are heightened. Milostan v. Brown, 4 Vet. App. 250, 252 (1993). In addition, when VA is unable to produce records that were once in the government's custody an explanation should be given a claimant as to how service treatment records are maintained, why the search that was conducted constitutes a reasonably exhaustive search, and why further efforts are not justified. 38 U.S.C.A. § 5103A(b)(2). The RO complied with these requirements in a September 2009 letter, which provided the relevant information regarding the missing service treatment records. In addition, pursuant to the Board's December 2011 remand instructions, the Veteran was afforded a VA examination and an opinion was secured addressing the etiology of his cervical spine, and left arm and hand disabilities. The examination and opinion provided were adequate for the reasons stated below. The Board will therefore proceed to the merits of the appeal, keeping in mind its heightened duties with regard to provide reasons and bases and consider the benefit-of-the-doubt rule. Analysis PTSD Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's posttraumatic stress disorder with adjustment disorder and depression is rated under under 38 C.F.R. § 4.130, Diagnostic Code 9411. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The maximum schedular 100 percent rating for a psychiatric disability is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). The Veteran contends that the currently assigned evaluation does not adequately reflect the severity of his disability. At the October 2011 hearing, he reported daily nightmares and flashbacks. He testified that sometimes he had panic attacks and was easily angered. He reported sometimes feeling homicidal or suicidal. He did report having a few friends and spending time with his grandchildren. He tried to do things around the house but felt that his PTSD was worse and he was somewhat more depressed. A January 2010 VA progress note indicates that the Veteran was complaining of nightmares related to his service in Korea. The Veteran was awake, alert, and oriented. He was referred to mental health for PTSD. The Veteran subsequently underwent a mental health diagnostic assessment consult. He reported that for the past two to three months he had been waking up with nightmares of Korean War events. He also reported a two to three month history of low energy, decreased appetite, and sadness. He reported being hypervigilant, and that he had panic attacks every other day. The panic attacks were sometimes triggered by stress and sometimes they were spontaneous. He denied any thoughts of suicide, as well as any history of suicide attempts or violence. On mental status examination, the Veteran was described as slowed, elderly, and well groomed. Behavior was appropriate. Psychomotor activity was slowed. His mood was flat and depressed and affect was blunted. There were no signs of suicidal ideation, hallucinations or delusions. His thought processes were normal, and memory and orientation were good. His judgment was okay but his insight was poor. Axis I diagnoses were new onset posttraumatic stress disorder, late onset major depression, and panic disorder. A global assessment of functioning score of 75 was assigned. The psychiatrist noted that posttraumatic stress disorder and depression seemed to have onset together over the past few years for no apparent reason. It was noted that a patient with hypertension at this age likely had white matter disease in the brain and a small stroke could have set the stage. The Veteran was started on Sertraline for depression and Ativan for anxiety and panic. A February 2010 mental health note indicates that the Veteran was doing some better with fewer nightmares. He was still irritable, and while his depressive symptoms were not worse, there was no improvement. On mental status examination his behavior and speech were normal. His affect was depressed, but with a hint of an occasional smile which was slightly improved from last visit. There was no suicidal or homicidal ideation, hallucinations or delusions. His thought processes were normal, and his memory and orientation were good. His judgment remained fair. His insight was poor. A March 2010 magnetic resonance image study of the brain showed signs of cerebellar atrophy. A March 2010 mental health note indicates that the Veteran still has an occasional nightmare. Daytime anxiety was better but he still lacked energy. He reportedly spent most days sitting alone or with the TV. He declined to attend Easter services with his grandchildren because of his fear of crowds and lack of energy. On mental status examination his speech was normal, but slow, with some speech latency. A restricted range of affect was noted with some laughter. His thought processes were linear, and memory and orientation were good. His judgment was also good but insight was only fair. The psychiatrist noted that the Veteran was able to take the medications and was showing some improvement but seemed to have plateaued with significant remaining symptoms. The Veteran underwent a VA PTSD examination in June 2010. On examination, the Veteran was neatly dressed. His speech was garbled and he sat back throughout most of the session in a relaxed state. His thought processes were within normal limits. The Veteran reported that he isolated himself and spent most of his time alone. He reported a history of being angry and irritable, and was easily upset and frequently nervous. He reported being sad and depressed over the prior four to five years since his neck operation and corresponding loss of mobility. He endorsed sleep difficulties. Jet planes and loud noises cause anxiety. On mental status examination his hygiene was noted to be clean and neat. His affect was serious and within normal limits. His current mood was reported as both sad and nervous. He denied hallucinations or delusions, as well as suicidal or homicidal ideation. The examiner opined that the Veteran had difficulty communicating and it was hard to understand him, but the appellant had no difficulty understanding the examiner. His memory was reported as fading. His focus and concentration were reported to be limited. The examiner noted that the appellant's mood had significantly deteriorated since the 2006 operation. The examiner opined that due to his stroke symptoms, the Veteran was incapable of working or managing his monies. It was noted that the Veteran experienced startle response, insomnia, fight/flight response, avoidance behavior and intrusive memories. The Axis I diagnoses were an adjustment disorder with depressed mood, and PTSD. A global assessment of functioning score of 58 was assigned. In his July 2010 notice of disagreement, the Veteran stated that he told the doctor that he had hallucinations, delusions, and suicidal and homicidal ideations. He referenced that portion of the report where the physician said he was hard to understand. In a subsequent July 2010 statement, the Veteran reiterated suicidal and homicidal thoughts. The Veteran underwent a VA aid and attendance examination in December 2010. He denied any memory loss. The examiner indicated that he required regular assistance to protect him from the hazards of his daily environment with falls and he was restricted to his immediate home. The examiner, however, made no finding that symptoms due to posttraumatic stress disorder led to a need for aid and attendance. The Veteran most recently underwent a VA examination on June 3, 2011. He was appropriately attired and appeared to be mildly halting intellectually. The Veteran reported that he retired in January 1997 and his wife indicated that he could not get around much and was not very active. He watched TV. The examiner noted that psychiatric medications were discontinued by the Veteran's primary care physician. The appellant's then present symptoms were poor sleep and poor concentration. The Veteran's wife stated that the appellant did not want to be bothered with many things and she had to stay and care for him. The Veteran's wife described the frequency of psychiatric symptoms as "pretty steady" and severity as "probably mild". She noted that the Veteran was 79 and was slowing down in every way. The examiner concurred and noted that he saw the appellant's gentle decline into old age, generally with a mild increase in PTSD symptoms. The Veteran's wife indicated that the claimant acted up a bit and it was difficult to make sure he kept clean. She stated that the quality of his peer relationships was "less and less so now." The Veteran's wife described social relationships as "church." The Veteran was not assaultive and his wife had not heard of any suicide statements or attempts. An impairment of thought processes was evident, but mild. The examiner noted the Veteran seemed quite happy to remain relatively vegetative. The claimant was aware of person, place, time and situation, but was fixated on speaking of his physical conditions. Their marital relationship was described as loving, and family relationships were noted. The appellant's speech, however, was perseverative and rambling. The Veteran did not complain of sleep impairment. The examiner noted that the Veteran's social functioning appeared moribund. The Axis I diagnosis was chronic, moderate posttraumatic stress disorder; no change noted at this time. A global assessment of functioning score of 53 was assigned. In considering the merits of the claim, the medical records suggest the Veteran experienced a stroke or had stroke-like symptoms. Examinations of record have not indicated whether any of the Veteran's symptoms are related to same, as opposed to posttraumatic stress disorder with adjustment disorder and depression. When it is not possible to separate the effects of the service-connected condition from any nonservice-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant's favor and that such manifestations be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). On review, the Board finds that the disability picture pertaining to the Veteran's posttraumatic stress disorder with adjustment disorder and depression between November 20, 2009 and June 3, 2011 most nearly approximated the criteria for a 70 percent evaluation. In this regard, while 38 C.F.R. § 4.126(b) requires consideration of the fact that the June 2011 examiner found the appellant socially moribund, that regulation also holds that VA is prohibited from assigning an evaluation solely on the basis of social impairment. Further, while the evidence does not show that the appellant suffers from near continuous panic, suicidal ideation, or obsessional rituals; and while the record shows that examiners have described the appellant as suffering from moderate posttraumatic stress disorder, the record does show that his social relationships are deficient, his speech is difficult to follow, and his wife has to assist him with his personal appearance. Hence, the Board will resolve reasonable doubt in the appellant's favor and award a 70 percent rating for the term from November 20, 2009 and June 3, 2011. The Board finds, however, that during the term from November 20, 2009 and June 3, 2011, that the Veteran's posttraumatic stress disorder with adjustment disorder and depression was not manifested by total social and occupational impairment. Again, it bears emphasis that a rating shall not be based on social impairment alone. 38 C.F.R. § 4.126. Further, the evidence preponderates against finding that due to his service connected psychiatric disorder the appellant had symptoms such as persistent delusions, hallucinations, grossly inappropriate behavior, or that he was in persistent danger of hurting self or others. There is no evidence showing that the Veteran due to his psychiatric disorder was intermittently unable to perform activities of daily living, or that he was been disoriented to time or place. Further, there is no evidence that his psychiatric disorder caused a memory loss for names of close relatives, own occupation, or own name. Hence, entitlement to a 100 percent rating for the term at issue is denied. Service Connection Claims Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is warranted for a disease first diagnosed after discharge 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). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, arthritis is presumed to have been incurred in service if manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In this case, the Veteran has been diagnosed with multiple disorders of the cervical spine and underwent surgery for cervical stenosis and cervical myleopathy. These diagnoses include degenerative changes. Although degenerative changes are not specifically referenced as a chronic disease is 38 C.F.R. § 3.309(a), the Court has long recognized that degenerative joint disease and degenerative changes denote the presence of arthritis. See Giglio v. Derwinski, 2 Vet. App. 560, 561 (1992) (referring to "Degenerative joint disease, or osteoarthritis"). The Board therefore finds that the chronicity and continuity provisions of 38 C.F.R. § 3.303(b) are applicable in this case. In addition, the Veteran claims that he suffered an in-service neck injury to which his current cervical spine disability is related. He also indicated that left arm and hand disabilities began in the 1970s, and are related to the cervical spine disability and thus to the same in-service neck injury. VA treatment records and the August 2012 VA examination report contain diagnoses of cervical radiculopathy of the left arm and hand. The evidence thus reflects that the left hand and arm disabilities are related to the cervical spine disability. The issue in this case is therefore whether a cervical spine disability, and related left hand and arm disabilities, are related to the in-service neck injury, regardless of whether the left arm and hand claims are characterized as secondary. See 38 C.F.R. § 3.310(a). As noted, the service treatment records, other than the separation examination report and report of medical history, are unavailable for review. The Veteran's DD Form 214 reflects that he served in Korea and was awarded the Combat Infantryman's Badge. Pursuant to 38 U.S.C.A. § 1154(b), combat veterans may establish service incurrence of a disease or injury through satisfactory lay or other evidence which is consistent with the circumstances, conditions or hardships of service, even in the absence of official record of such incurrence. See also 38 C.F.R. § 3.304(d). The Veteran's reports of sustaining a neck injury during combat are consistent with the circumstances of his service. He has thus met the requirement of establishing in-service injury as well as current disability. Significantly, however, 38 U.S.C.A. § 1154(b) does not eliminate the need for evidence of a nexus. Rather, it merely reduces, for veterans who have engaged in combat with the enemy, the burden of presenting evidence of incurrence or aggravation of an injury or disease in service. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996) ("Section 1154(b) does not create a statutory presumption that a combat veteran's alleged disease or injury is service-connected"). The dispositive issues in this case are thus whether the Veteran's current cervical spine and left arm and hand disabilities are related to his in-service neck injury, on a continuity of symptomatology or other basis; or whether cervical arthritis manifested to a compensable degree within the one year presumptive period. For the following reasons, the Board finds that both questions must be answered in the negative. The Veteran has claimed in his written statements to some health care providers including the August 2012 VA examiner that he was hit in the back of the neck and head in service and that he has continued to have neck pain and symptoms since. The Veteran is competent to testify as to his observations, but this testimony must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). The other evidence of record weighs against continuity of symptomatology. Most significantly, all findings, including of the spine and other musculoskeletal systems, were normal on the November 1957 separation examination, and the Veteran indicated in the contemporaneous report of medical history that he was in good health and that he did not have, and had never had, arthritis or rheumatism, bone, joint, or other deformity, lameness, or other orthopedic symptoms indicated on the applicable form. This evidence, including the Veteran's own contemporaneous statements, is of greater probative weight than his statements made many years later during an appeal from the denial of compensation benefits. Pond v. West, 12 Vet. App. 341, 345 (1999) (interest may affect the credibility of testimony). The Veteran's statements as to continuity of symptomatology are therefore not credible. Another factor that weighs against continuity of symptomatology, a factor to be considered but which is not dispositive, is that the earliest records of post service treatment for either cervical spine or left arm or hand disabilities were many years after service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Feb. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue). As to whether the current disabilities are otherwise related to the in-service neck injury, there are multiple opinions on this question. The June 2010 VA psychiatric examiner wrote, "This examiner cannot accurately determine if his current condition is directly related to a neck/head injury he endured while in combat in Korea; however, the Veteran believes that this was the initial cause of his problems." Such a statement, which recites the inability to come to an opinion, provides neither positive nor negative support for service connection. Fagan v. Shinseki, 573 F. 3d 1282, 1289 (Fed. Cir. 2009). Similarly, Dr. Strohmeyer, the Veteran's treating physician, wrote in a November 2009 letter that the appellant had a diagnosis of cervical myleopathy and underwent surgery, resulting in permanent disability, but he did not offer an opinion as to the etiology of this disability. The January 2012 VA examiner also diagnosed cervical spine degeneration and stenosis with radiculopathy, but he did not express an opinion as to the etiology of the disabilities. There are only two other opinions, that of a VA physician in February 2012 and that of the Veteran. The VA physician reviewed the claims file and concluded that the Veteran's current disability was less likely than not incurred in or caused by the claimed in-service injury. His rationale was that, although the Veteran stated that he was struck in the head in service and had neck pain since that time, there were no service treatment records, the separation examination report made no mention of neck problems, the examination was normal with no pertinent complaints, he did not have surgery until 2006 (many years later), and he worked for many years after service. As the VA physician reviewed the claims file and explained the reasons for his conclusion, his opinion is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Moreover, the physician acknowledged the Veteran's statements as to continuity of symptomatology but weighed this statement against the other evidence of the record and found, as does the Board, that the other evidence was of greater probative weight. The Veteran's lay statements were therefore not improperly discounted merely because they were lay statements. Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006). The Board has considered the statements of the Veteran indicating his belief that his cervical spine disability and related left arm and hand disability are related to the in-service neck injury. As he indicated in his December 2009 notice of disagreement and elsewhere, "If I did not have cervical spine stenosis [due to] service, then where did it come from." The Board is sympathetic to the Veteran's question, as current cervical spine disability and in-service neck injury have been established. Moreover, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's testimony as to whether any current cervical spine disability, and related left arm and hand disability, are related to in-service neck injury appears to be testimony as to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau, 492 F.3d at 1377, n.4 ("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"). In any event, to the extent that the Veteran is competent on this question, the Board finds the specific, reasoned opinion of the VA physician in February 2012 is of greater probative weigh than the more general lay assertions of the Veteran. The Veteran also reported during the October 2011 Board videoconference hearing that a physician at the Charleston VA Medical Center told him that his current disabilities were due to his in-service injury. Hearing Transcript, at 18. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when the layperson is reporting a contemporaneous medical diagnosis. Jandreau, 492 F.3d at 1377. Here, the record was held open for the Veteran to provide additional evidence, including a letter from a physician containing the statement he claimed was made to him orally. Hearing Transcript, at 19. The appellant did not provide such evidence and there is no such statement in any of the VA treatment records in the claims file. The Board is therefore left with only the Veteran's description of a general opinion expressed by a physician. For the reasons indicated above, the specific, reasoned opinion expressed by the VA physician in February 2012 is of greater probative weight than that of the physician's statement recounted by the Veteran, even assuming that the appellant accurately relayed what was stated to him. For the foregoing reasons, the preponderance of the evidence is against the claims for entitlement to service connection for cervical spine and left arm and hand disability. The Board has carefully considered the benefit-of-the-doubt doctrine, but given that the preponderance of the evidence is against the claim as shown above, the doctrine is not for application. See 38 U.S.C.A. § 5107(b). To the extent that the left hand and arm disabilities are claimed on a secondary basis, as the primary disability has been found not to be service connected, the secondary claim must be denied as a matter of law. 38 C.F.R. § 3.310(a), (b) (secondary service connection is awarded when disability is proximately due to, the result of, or aggravated by a service-connected disease or injury). ORDER A 70 percent rating is granted for PTSD with adjustment disorder and depression from November 20, 2009 to June 3, 2011, subject to controlling regulations governing the payment of monetary awards. Entitlement to service connection for residuals of a neck injury is denied. Entitlement to service connection for nerve damage of the left arm and hand, to include secondary to a neck injury, is denied. REMAND The Veteran was last examined for his posttraumatic stress disorder with adjustment disorder and depression in June 2011, i.e., almost three years ago. In light of the appellant's testimony concerning the severity of the disorder the Board finds further development to be in order. Therefore, this case is REMANDED for the following action: 1. The RO/AMC should obtain any outstanding treatment records regarding care for PTSD with adjustment disorder and depression dating since June 2011. Any records obtained must be associated with the Veteran's claims folder. If the RO cannot locate any identified record, the RO/AMC must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The claimant must be given an opportunity to respond. 2. Thereafter, the Veteran must be afforded a VA psychiatric examination. The examiner is to be given access to the claims folder, a copy of this REMAND and Virtual VA. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner is to provide a detailed review of the appellant's pertinent medical history, current complaints, and the nature and extent of any disability due to PTSD with adjustment disorder and depression. The examiner should note whether there has been an increase in severity since the last examination in June 2011, if so, the approximate date of the increase in severity. The examiner must carefully differentiate all pathology caused by cerebral atrophy, stroke residuals and any other nonservice connected disorder from pathology caused by PTSD with adjustment disorder and depression. The examiner must opine whether it is at least as likely as not, i.e., is there a 50/50 chance, that the Veteran is unable to obtain and retain substantially gainful employment based on PTSD with adjustment disorder and depression alone. A complete rationale for any opinion offered must be provided. 3. The Veteran is to be notified that it is his responsibility to report for the scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 , 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examinations was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 4. After the development requested, the RO/AMC should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The AMC/RO must ensure that the examiner documented their consideration of Virtual VA, to include identifying the date range of Virtual VA records reviewed. If the report is deficient in any manner, the RO must implement corrective procedures at once. 5. Upon completion of the above requested development and any additional development deemed appropriate, readjudicate the issue of what evaluation is warranted for PTSD with adjustment disorder and depression from June 4, 2011. All applicable laws and regulations should be considered. If any benefit is not granted, the Veteran and his representative should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs