Citation Nr: 1317013 Decision Date: 05/23/13 Archive Date: 05/31/13 DOCKET NO. 07-05 255 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from September 29, 1976 to November 10, 1976. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In July 2011, the Board remanded the Veteran's case to the RO for scheduling of a hearing before a Veterans Law Judge (Board hearing). In May 2012, the Veteran, through her representative, requested that her hearing be rescheduled, as she was incarcerated. In July 2012, the Board remanded the Veteran's case to the RO to comply with her request. The Veteran was scheduled for a Board hearing at the RO in October 2012 but failed to appear and did not request that the hearing be rescheduled. The Board finds that all due process requirements were met regarding the Veteran's hearing request. In a December 2012 decision, the Board determined that new and material evidence was received to reopen the Veteran's previously denied claim for service connection for an acquired psychiatric disorder. At that time, the Board remanded the reopened claim, to include PTSD, to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further development. In March 2013, the Board again remanded the Veteran's case to the RO via the AMC for further development. FINDING OF FACT The evidence of record preponderates against a finding that an acquired psychiatric disorder, including PTSD, had its onset or is otherwise related to the Veteran's military service and a psychosis was not manifested to a compensable degree within one year of discharge from active service. There is no evidence of superimposed injury or disease that caused resultant psychiatric disability in military service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.655 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and 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 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in August 2005, January and October 2010, and January 2013, that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The October 2010 letter provided notice as to how VA assigns an appropriate disability rating or effective date, curing any timing defect. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of her claim. This duty includes assisting her in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claim for service connection for an acquired psychiatric disorder. The December 2012 remand was ordered to obtain records of private psychiatric treatment from 1976 to 1979 and schedule the Veteran for a VA examination in conjunction with her claim. The Veteran did not respond to the AMC's January 2013 letter requesting that she provide signed authorization for VA to obtain records from any private physician that treated her psychiatric condition from 1976 to 1979. The VA examination was scheduled in accordance with the Board's remand instructions, in February 2013, but the Veteran failed without explanation to report. There is no indication in the record that the letter notifying the Veteran of the scheduled February 2013 VA mental disorders examination was not received. See Ashley v. Derwinski, 2 Vet. App. 62 (1992) (regarding the presumption of regularity that public officers have properly discharged their official duties in absence of clear evidence to the contrary); Mindenhall v. Brown, 7 Vet. App. 271 (1994) (regarding the applicability of the presumption of regularity to RO actions). The report from the VA medical facility notes that the Veteran failed to report for the scheduled examination. The February 2013 supplemental statement of the case informed the Veteran of her failure to report (see page 8) and there being no showing in the record of good cause for her failure to report. There is no record in the claims folder of a response from the Veteran. In short, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. The Board finds that additional efforts to schedule an examination would be futile. In the absence of clear evidence to the contrary, the law presumes the regularity of the administrative process. Notification for VA purposes is a written notice sent to the claimant's last address of record. See 38 C.F.R. § 3.1(q) (2012). While VA has a statutory duty to assist in developing evidence pertinent to a claim, the Veteran also has a duty to assist and cooperate with the VA in developing evidence; the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190 (1991). VA's duty must be understood as a duty to assist the Veteran in developing her claim, rather than a duty on the part of VA to develop the entire claim with the Veteran performing a passive role. Turk v. Peake, 21 Vet. App. 565, 568 (2008). Therefore, remand for an additional VA examination is not warranted as to the claim for service connection for a psychiatric disorder, including PTSD. The Board has no legal recourse but to decide the Veteran's claim on basis of the existing record. 38 C.F.R. § 3.655. As noted above, in March 2013, the Board remanded the Veteran's case to the RO for further development that included obtaining recent VA medical records, dated from October 2006 to July 2010. There has been substantial compliance with the Board's 2013 remand as VA medical records, dated from October 2006 to March 2013, were obtained and added to the Veteran's electronic record file. The Board finds that all necessary development has been accomplished and, therefore, appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and non-VA treatment and examinations, to the extent available, records obtained from the Social Security Administration (SSA) and considered in conjunction with her claim for disability benefits, and written statements in support of her current claim on appeal. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Factual Background and Legal Analysis The Board notes that it has thoroughly reviewed the record in conjunction with this case that includes the Veteran's service treatment records, VA and non-VA medical records and examination reports, dated from 1979 to 2013, and the Veteran's written statements in support of her claim. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Under 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Nevertheless, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, case law has established 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). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). To establish a right to compensation for a present disability, a veteran must 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" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. Certain chronic diseases, such as psychoses, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. This is also a direct service connection theory of entitlement. A service connection claim must be accompanied by evidence that establishes that the claimant currently has the claimed disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Congenital or developmental defects and personality disorders are not diseases or injuries within the meaning of the applicable legislation. See 38 C.F.R. § 3.303(c), 4.9 (2012); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). VAOPGCPREC 82-90 (July 18, 1990) (a reissue of General Counsel opinion 01-85 (March 5, 1985)) in essence held that a disease considered by medical authorities to be of familial (or hereditary) origin by its very nature preexists a claimant' s military service, but could be granted service connection if manifestations of the disease in service constituted aggravation of the condition. Congenital or developmental defects, as opposed to diseases, could not be service-connected because they are not diseases or injuries under the law; however, if superimposed injury or disease occurred, the resultant disability might be service-connected. Id. Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of psychiatric pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining whether service connection is warranted for a disability, 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 preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In written statements in support of her claim, the Veteran asserts that she has a psychiatric disorder, including PTSD, due to military service. In May 1997 correspondence and in February 2010, the Veteran indicated that she successfully completed two years of service in the Navy Reserve Officers Training Corps (ROTC) and had no problems until entry into active service. In February 2007, she submitted a copy of her Certificate of Completion of Navy Junior ROTC and reiterated that her psychiatric disorder began during boot camp in active military service. She said that she was harassed by other Seamen because of her voice. In October 2009, the Veteran raised the matter of entitlement to service connection for PTSD. In February 2010 written statements, she asserted that her PTSD was caused by the cruelty and mistreatment of Naval commanding officers in boot camp in Great Lakes, Illinois. She received verbal abuse from commanding officers and sailors and was humiliated in front of an entire boot camp company due to her voice, mannerisms, and character. The Veteran stated that the foul language and mistreatment to which she was exposed caused her PTSD that she did not experience prior to entering active service. Upon review of the evidence of record, and after considering the laws and regulations applicable to the Veteran's claim, the Board finds that service connection is not warranted. Prior to July 13, 2010, service connection for PTSD required: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2009), effective prior to July 13, 2010. However, effective July 13, 2010, 38 C.F.R. § 3.304 (f) was amended to include a new paragraph (f)(3) that reads as follows, in pertinent part: (f)(3) If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and 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. See 75 Fed. Reg. 39843 -51 (July 13, 2010) and corrective notice at 75 Fed. Reg. 41092 (July 15, 2010). The provisions of this amendment do not apply to the Veteran's claim because she attributes her acquired psychiatric disorder to personal (verbal) assault. The Board recognizes that the present case falls within the category of situations, to include allegations of personal assault, in which it is not unusual for there to be an absence of service records documenting the events of which the Veteran alleges. See, e.g., Patton v. West, 12 Vet. App. 272, 281 (1999). 38 C.F.R. § 3.304(f) reflects a recognition that service records may not contain evidence of personal assault, and that alternative sources, including testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, may provide credible evidence of an in-service stressor premised on personal assault. See YR v. West, 11 Vet. App. 393, 399 (1998). Under 38 C.F.R. § 3.304(f)(3), if a PTSD claim is based on in-service personal assault, evidence from sources other than the service records may corroborate the Veteran's account of the stressor incident. The Board notes that the Veteran failed to respond to the RO's January and October 2010 letters requesting that she provide the specifics of her alleged stressful events in service. She also did not respond to the AMC's January 2013 letter requesting similar information. Even assuming, arguendo, that the Veteran's alleged stressors are verifiable or are consistent with the places, types, and circumstances of her service, the medical evidence of record fails to establish a link between a current diagnosis of PTSD and her claimed in-service stressors. Service treatment records show that, on a Report of Medical History completed in August 1976 when the Veteran was examined for entry into service, he (the Veteran was a male at that time) denied having depression or excessive worry, trouble sleeping, or nervous trouble of any sort. A psychiatric abnormality was not noted on examination at that time and he was found qualified for active service. During service, the Veteran was referred for psychiatric evaluation by his company commander. A November 1976 psychiatric evaluation associated with an Aptitude Board report indicates that the Veteran had a lifelong history of bedwetting that the examiner opined was symptomatic of the Veteran's immaturity, poor judgment, and lack of insight. No organic basis for the Veteran's bedwetting was found. It appeared that the Veteran's bedwetting was a response to minor emotional stress. The examiner concluded that the Veteran lacked the necessary maturity to function effectively in the Navy, and recommended that the Veteran be discharged as temperamentally unsuitable for further training. The Veteran's service personnel records include his Enlisted Performance Record. It indicates that he was not recommended for reenlistment due to unsuitability due to personality disorders and was discharged in November 1976. Post-service, in an October 1978 application for SSA disability benefits, the Veteran reported his illness or injury as "having gender problems," "sex change," and liver problems. He stated that his illness or injury first bothered him in September 1970 and finally disabled him in December 1975. The Veteran described being under mental strain and was undergoing "sex change surgery". He did not associate his mental disorder with his active military service. Records considered by the SSA in conjunction with the Veteran's disability claim include a January 1979 report from a private physician who described treating the Veteran since June 1978 and diagnosed him with a depressive neurosis. A March 1979 private psychiatric evaluation performed in conjunction with the Veteran's SSA disability claim revealed complaints of hearing voices and feeling like needles were in his head. He had tried to commit suicide by overdose of pills in 1978 because he thought someone was trying to kill him. At that time, he was hospitalized for two weeks. The Veteran denied any other psychiatric hospitalizations but stated that he consulted with psychiatrists intermittently over the past two to three years. He also admitted to gender issues and expressed interest in a sex change. Mental status examination revealed that the Veteran had inconsistent comprehension and concentration, and a flat and distant affect with underlying depression and apathy. The Veteran's appearance and mannerisms were moderately effeminate. The diagnosis was schizophrenic reaction, chronic, undifferentiated; and gender dysphoria, male to female transsexual. In March 1979, the SSA determined that the Veteran was totally impaired and unable to work due to a chronic, undifferentiated schizophrenic reaction, and granted his claim for disability benefits. According to a September 1980 private psychiatric evaluation, the Veteran was interviewed while incarcerated in a county jail. He was considered an extremely poor and unreliable historian in that he was unable to answer many of the examiner's questions, was vague about facts and details of his history, often gave contradictory answers, and was unable to provide coherent answers. He said he was disabled because his "mind comes and goes" by which he meant that he had auditory and visual hallucinations, had a "gender problem", and occasionally hurt all over. He denied prior psychiatric hospitalization but said that he saw a psychiatrist regularly, but not for over five months. The Veteran was unable to give the name and address of the psychiatrist and was vague in recalling if he ever had prior psychiatric medication. He was arrested nine months earlier and was in jail continuously since that time. The Veteran was unable to explain how he could be in jail for nine continuous months and yet saw his psychiatrist at the doctor's office five months earlier. Objectively, the Veteran's manner and gestures were effeminate. His affect was flat and inappropriate and he occasionally made an inappropriate laugh. His answers to questions rambled from conversational goals and often were unrelated to the question asked. There was evidence of delusions. He reported auditory hallucinations of voices in his head and visual hallucinations of a smiling face. The Veteran could not do simple mathematical calculations and was unable to concentrate. The diagnosis was a schizophrenic illness, possibly Hebephrenic schizophrenia. An August 1985 VA psychiatric examination report indicates that the Veteran's grandmother noted that he lived with her prior to entering service and seemed to be a very much changed person when he returned to her home in November 1976. She stated that the Veteran worked, went to school, and was very actively involved in various types of activities prior to leaving for active service but, on his return, simply stayed in the house, cried a lot, and talked in a confused manner. The Veteran's grandmother also said that a doctor told her at the time that the Veteran had a nervous breakdown but, rather than take him, as suggested, to apply for SSA disability benefits, she gave him some of her Valium that quieted him down. On mental status examination, the Veteran was disoriented and exhibited a vacuous appearance with an open mouth and flattened affect, that the VA examiner remarked was the appearance of someone who had a chronic mental condition, likely schizophrenia, for some time. The examiner commented that the Veteran did not appear to be employable or competent. In 1994 or 1995, the Veteran underwent surgical sex change, according to June 2004, October 2005, and February 2006 VA outpatient records, respectively. December 1997 private medical records indicate that the Veteran was hospitalized for treatment of Acquired Immune Deficiency Syndrome (AIDS). These records indicate that she had no past surgical history and was a transsexual. The records describe a history of depression and anxiety. The Veteran's SSA disability benefits were ceased effective February 2002, on the basis that drug addiction and alcoholism were both material factors to a finding of disability since the March 1979 determination, according to an August 2002 SSA hearing officer's Analysis of Evidence and Finding of Fact. Records associated with the Veteran's February 2002 SSA reconsideration claim include her formal claim in which she reported being disabled by schizophrenia and HIV/AIDS and hospitalized in 1980 for treatment of schizophrenia. A January 2002 private psychiatric evaluation performed for the SSA reportedly yielded diagnoses of bipolar disorder, gender identity disorder, schizotypal personality disorder, and polysubstance abuse. Symtoms of depression were also noted. See August 2002 SSA Analysis of Evidence and Findings of Fact. The SSA hearing officer concluded that the Veteran was disabled. VA medical records, dated from May 2004 to March 2013, reflect the Veteran's treatment for a schizoaffective disorder, bipolar type II. An October 2005 mental hygiene note shows that she denied having any PTSD symtoms. With respect to the Veteran's claim of service connection for PTSD, in the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. at 225. Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of PTSD, the Board must conclude the Veteran does not suffer from such a disability currently or at any time during the rating period on appeal. The Board is mindful that a claim should be broadly construed, and thus the instant claim encompasses diagnoses beyond PTSD. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009); see infra. The Veteran also contends that service connection is warranted for an acquired psychiatric disorder, other than PTSD. Although the evidence shows that the Veteran currently has a schizoaffective disorder, no competent medical evidence has been submitted to show that this disability is related to service or any incident thereof. Her service medical records are completely silent for any complaints of, or treatment for, a schizoaffective disorder. In addition, when examined for separation from service in November 1976, although a personality disorder was noted on the Veteran's Enlisted Performance Record, a psychiatric abnormality was not reported. Moreover, the first post-service evidence of record of treatment for a psychiatric disorder is from June 1978, nearly 18 months after the Veteran's separation from service (when treatment for depressive neurosis was reported.) Here, there is no evidence that the Veteran was diagnosed with a psychosis within one year of his separation from active service in November 1976 and the record fails to show that a psychosis was manifested to a compensable degree within the one year following his active duty service discharge in November 1976. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In short, no medical opinion or other medical evidence relating the Veteran's psychiatric disorder to service or any incident of service has been presented. As noted above, the Veteran failed to report for a VA mental disorders examination scheduled in February 2013, in conjunction with her claim. The Veteran has offered no explanation as to why she failed to appear for the scheduled examination. A letter dated in January 2013 informed her that a request had been sent to the VA medical facility "nearest you" to schedule her for an examination, that she would be notified of the date and location of the examination, and that her claim would be rated on the evidence of record, or could be denied, if she failed to report for an examination. Given the presumption of regularity of the mailing of VA examination scheduling notice and the fact that the Veteran has not contacted the RO with a reason for her failure to report, the Board finds that the Veteran failed to report to the scheduled February 2013 VA examination without good cause. See 38 C.F.R. § 3.655. There is not one medical opinion of record to support her service connection claim. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655. When a veteran fails without good cause to report for a VA examination requested by VA in conjunction with a claim, VA is not obliged to attempt to provide another. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a). VA offered the Veteran an opportunity to have a VA examination to obtain a medical opinion regarding whether she had a psychiatric disorder incurred in or related to her military service. The Veteran, however, failed to appear for the scheduled VA examination. Her failure to cooperate in attending the examination has left the record devoid of any competent opinion whether she has a psychiatric disorder that was incurred in or related to her active military service. 38 C.F.R. § 3.655(b). Given that there is no competent evidence that the claimed disorder is aggravated by a service connected disorder, given that the Veteran failed to report for the scheduled examination, and given that she has not provided good cause for her failure in this regard, his claim must be denied. While VA has a duty to assist the Veteran in the development of a claim, that duty is not limitless. In the normal course of events, it is the burden of the Veteran to appear for VA examinations. If she does not do so, there is no burden on the VA to "turn up heaven and earth" to find her. Hyson v. Brown, 5 Vet. App. 262 (1993). In sum, the Veteran was aware of the consequences of a failure to report for VA examination without good cause. She has not shown good cause for her failure to appear for the VA examination scheduled in February 2013. The Board finds that the Veteran failed to report to the scheduled February 2013 VA examination without good cause. See 38 C.F.R. § 3.655(b). As such, her claim must be rated based upon the evidence of record. Id. In deciding whether good cause was shown for the Veteran's failure to report for the necessary examination, the Board has considered the doctrine of reasonable doubt, but the preponderance of the evidence is against a finding that there was good cause and reasonable doubt does not arise. The Veteran reported having various alleged stressors associated with her military service, although there is no medical evidence reflecting treatment for a psychiatric disorder prior June 1978, nearly 18 months after the Veteran's separation from active service in 1976, when treatment for a depressive neurosis was reported. There is no competent medical evidence of record to support the Veteran's claim. In so finding, the Board has considered the Veteran's contention that a relationship exists between her current psychiatric disorder, diagnosed as schizoaffective disorder, and military service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the United States Court of Appeals for Veterans Claims (Court), emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). The Veteran is competent to describe her observable symptoms, such as nervousness. However, she is not competent to make a statement of causation that is a medical determination. Barr v. Nicholson, 21 Vet. App. at 303; Buchanan v. Nicholson, 451 F.3d at 1331. To the extent she is claiming that psychiatric problems have persisted since service, this is inconsistent with the overall record, which reflects that her psychiatric symptomatology manifested after service. The Board has considered the Veteran's statements as to her incurrence during service, in light of her service treatment records and post-service medical evidence. The Board finds that the objective medical evidence of record is most persuasive and of more probative value than the appellant's assertions. The record reflects a history of enuresis found to be a response to minor emotional distress but fails to reflect that the Veteran was treated on even one occasion for psychiatric difficulty during military service. The post service records show that a depressive neurosis was reported in January 1979 and a schizophrenic reaction and gender dysphoria were diagnosed in March 1979, nearly 3 years after her discharge from service. The gap of time between military service and the first post-service medical evidence of a psychiatric disorder is, in itself, significant, and weighs against the appellant's claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (to the effect that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board recognizes that the absence of documented post-service treatment cannot, by itself, invalidate the Veteran's claims of continuous symptomatology. However, to the extent that the Veteran is claiming continuity of psychiatric symptoms since service, she is not a reliable historian. She made no mention of psychiatric problems during her August 1976 service examinations and a psychiatric abnormality was not noted on examination at that time. She has not explained why she failed to mention pertinent difficulty when examined pursuant to service requirements. But, in October 1978, the Veteran told the SSA that her psychiatric disorder first bothered her in September 1970, nearly six years prior to entering active service. Further, in March 1979, the Veteran told a private psychiatrist that she consulted psychiatrists intermittently over the past two or three years, but she failed to provide signed authorizations for VA to obtain records of this treatment between 1976 and 1979. The Board does not find that there is credible evidence of continuity of symptomatology present in this case. Moreover, while the Veteran is competent to state that she experienced psychiatric problems in service, she is not competent to state that she has a schizoaffective disorder or another psychiatric disease. The psychiatric pathology of schizoaffective disorder is not readily recognizable by a layman, such as varicose veins or acne. See Jandreau v. Nicholson. Even medical professionals rely on psychiatric measurement and diagnostic tools to diagnose schizoaffective disorder. As to the Veteran's personality disorder noted as the reason for separation on her Enlistment Performance Record, it cannot be service-connected because it is not a disease or injury for VA compensation purposes; however, if superimposed injury or disease occurred, the resultant disability might be service-connected. 38 C.F.R. § 3.303(c). However, the record is totally devoid of any superimposed injury or disease in service that caused a resultant psychiatric disability. Further, a psychiatric disorder was not diagnosed during the Veteran's period of service and, despite her contentions that she experienced psychiatric symptoms since such service, and although she complained of stress in 1976, available records document that she received psychiatric treatment that started in June 1978, not right after her military service. The negative clinical and documentary evidence post service for approximately two years after her active service is more probative than the remote assertions of the Veteran. The lack of continuity of treatment may bear in a merits determination on the credibility of the evidence of continuity of symptoms by lay parties. Savage v. Gober, 10 Vet. App. 488, 496 (1997). Further, VA treatment records, dated from 2004 to 2013, show that the Veteran has a schizoaffective disorder. Not one clinician attributed the disorder to her military service. The Veteran's contentions are outweighed by the objective medical evidence that reflects that her schizoaffective disorder was less likely as not related to her active military service. In sum, the Board is left with a history of enuresis prior to and during service, but no documented complaints of psychiatric problems in service, no documented complaints or findings of a diagnosed a schizophrenic reaction after service until 1979, and not one medical opinion to support the Veteran's claim. In sum, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for an acquired psychiatric disorder, including PTSD, and her claim must be denied. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). CONTINUED ON NEXT PAGE Finally, the Board notes that the March 1979 record indicates that the SSA found the Veteran suffering from a chronic, undifferentiated schizophrenic reaction, and held him to be totally disabled since January 1979. While the Board recognizes the disabling nature of the Veteran's psychiatric disability, the SSA decision is not considered sufficient to overcome the objective evidence of record as to the origin of the Veteran's claimed acquired psychiatric disorder, including PTSD. ORDER Service connection for a psychiatric disorder, including PTSD, is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs