Citation Nr: 1317510 Decision Date: 05/29/13 Archive Date: 06/06/13 DOCKET NO. 08-15 350 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include depression, bipolar disorder, and posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1974 to September 1976. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This case was remanded by the Board in December 2009 and June 2012 for further development and is now ready for disposition. In an April 2012 letter, the Veteran withdrew his request for a Board hearing. The Board finds there is no hearing request pending at this time. 38 C.F.R. § 20.702(e) (2012). FINDINGS OF FACT 1. A diagnosis of a psychosis is not shown. 2. A current acquired psychiatric disorder, to include depression, bipolar disorder, and PTSD, was not shown to be chronic in service nor is it related to any incident of service. CONCLUSION OF LAW An acquired psychiatric disorder, to include depression, bipolar disorder, and PTSD, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.304(f), 3.307, 3.309, 3.384 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran contends that his psychiatric disorder is causally related to his period of active service, to include combat exposure and a sexual assault incident. He is seeking service connection for an acquired psychiatric disorder, to include depression, bipolar disorder, and PTSD. The Board has reviewed all of the evidence in the Veteran's physical claims folder and on the "Virtual VA" system. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned, continuity of symptoms is required. 38 C.F.R. § 3.303(b). The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances lay evidence of a nexus between the present disorder and the post-service symptomatology. Clyburn v. West, 12 Vet. App. 296, 302 (1999). In this case, the evidence does not show the Veteran has ever been diagnosed with a psychosis. 38 C.F.R. § 3.384 (2012). Therefore, the claim on appeal is not listed as a "chronic disease" under 38 C.F.R. § 3.309(a), and 38 C.F.R. § 3.303(b) does not apply in this case. The third alternative for granting service connection is that certain chronic diseases, including psychoses, may be established based upon a legal presumption by showing that it manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. In this case, as noted above, the claim on appeal is not listed in 38 C.F.R. §§ 3.307, 3.309(a); therefore, the one-year presumption does not apply. Finally, service connection may be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (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 in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). With respect to the regulatory provision pertaining to service connection for PTSD, during the course of this appeal, VA amended 38 C.F.R. § 3.304(f). Prior to the amendment, in order for service connection to be warranted for PTSD, the record had to show: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); (2) combat status or credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between diagnosed PTSD and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (in effect prior to July 31, 2010). However, effective July 13, 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. The amended 38 C.F.R. § 3.304(f) adds the following: In 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 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. 38 C.F.R. § 3.304(f)(3); 75 Fed. Reg. 39,843-852 (July 13, 2010). The amendment to the regulation is effective, in pertinent part, for all claims pending at the Board on July 13, 2010, as here. In this case, the Veteran has asserted at various times that he had combat service, as noted in August 2000, September 2004, December 2010, and December 2011 VA outpatient treatment records. However, he is neither in receipt of any military citations indicative of combat service nor otherwise shown through service records to have had combat service. Further, February 2010 and April 2010 VA outpatient treatment records indicate he did not perform combat service. While there is certainly evidence that his military occupational specialty (MOS) was a rifleman and he received the National Defense Service Medal, such service does not necessarily connote combat service. There is no indication in the record that he was engaged in combat with the enemy during his period of active service. Therefore, the Board finds that the presumption afforded combat veterans under 38 U.S.C.A. § 1154(b) does not apply. However, because the Veteran has alleged fear of hostile military activity in a combat zone (i.e., being under combat fire in Cambodia), the Board has considered whether the amended regulatory provision, 38 C.F.R. § 3.304(f)(3), is applicable in this case. If a PTSD claim is based on in-service personal assault, evidence from sources other than a veteran's service records may corroborate the veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include that of behavior changes following the claimed assault, such as: request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. For VA purposes, "personal assault" is defined as an event of human design that threatens or inflicts harm, such as rape, physical assault and domestic battering, robbery and mugging, stalking, and harassment. See M21-1MR, Part III.iv.4.H.30.a (2012); M21-1MR, Part IV.ii.1.D.17.a (2012). In this decision, the Board has considered the lay evidence as it pertains to the issue. In rendering a decision on appeal, 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. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). "Competent medical evidence" means that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). "Competent lay evidence" is any evidence not requiring that the proponent have specialized education, training or experience, but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). A veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). With respect to evaluating the medical evidence, generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The United States Court of Appeals for Veterans Claims (Court) has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Post-service evidence reflects psychiatric symptomatology starting in May 1991. A September VA outpatient treatment record documented the Veteran's previous psychiatric history revealed that he had been hospitalized numerous times at different VA hospitals, specifically in 1991 and 1996. In May 1999, he was accepted into substance abuse treatment program (SATP) and reported that he was diagnosed with bipolar disorder when using cocaine and/or other drugs. In June 2000, the Veteran complained of depression and in August 2000 was diagnosed with chronic PTSD. In August 2004, he was diagnosed with bipolar affective disorder by history and depressive phase, as well as bipolar disorder not otherwise specified (NOS). The May 2006 VA examiner diagnosed recurrent major depressive disorder without psychotic features. Thereafter, an August 2011 VA outpatient treatment record documented diagnoses of bipolar disorder and PTSD. Therefore, an acquired psychiatric disorder, to include depression, bipolar disorder, and PTSD are currently shown and the first element has been met. The Board notes the Veteran was also diagnosed with personality disorder NOS pursuant to multiple VA outpatient treatment sessions. Nevertheless, there is no legal basis to grant service connection for a personality disorder, since personality disorders are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c) (2012); see Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Next, the Board notes in-service complaints of personal problems and treatment for gonorrhea. Specifically, March 1975 records document the Veteran's complaint of personal problems to include his brother in jail, and continuous dreams that his grandmother was ill. In August 1976, he complained of being tense and agitated and was assessed with questionable anxiety depression and explosive personality. Therefore, service treatment records reflect an in-service incurrence of psychiatric complaints and the second element has been met. With respect to the claim, as depression, bipolar disorder, and PTSD are not one of the chronic diseases listed in 38 C.F.R. § 3.309(a), 38 C.F.R. § 3.303(b) is not for application. Nonetheless, as a current acquired psychiatric disorder is currently shown and the evidence reflects in-service complaint of psychiatric symptoms, the next question is whether there is a casual relationship between the current complaints and the in-service incurrence of psychiatric complaints. As part of the current VA disability compensation claim, in recent statements, the Veteran has asserted that his acquired psychiatric disorder is related to service. He asserts that he experienced psychiatric symptoms of depression and bipolar disorder after he was discharged from the service. At VA treatment sessions in August 2000, he reported exposure to combat fire while in Cambodia for eight days, witnessing the loss of several close friends in the military and involvement with the retaking of the USS Maquass which was under fire in 1975. He also informed the May 2006 VA examiner that he was raped while inebriated during service by one other person and the incident depressed and traumatized him. In this case, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience psychiatric symptoms since service separation, his assertions of in-service combat exposure are inconsistent with the circumstances of his service and other lay statements, and his reported in-service sexual assault is not corroborated by the evidence of record. The Board concludes that his lay assertion of a nexus between active service and his current complaints, while competent, is not credible. The post-service medical evidence does not reflect complaints or treatment related to an acquired psychiatric disorder for multiple years following active service. The Board emphasizes the multi-year gap between discharge from active duty service (1976) and initial reported symptoms related to depression and bipolar disorder in approximately 1991 (nearly a 40-year gap). See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (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 Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability); see Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder). The Veteran did not claim that an in-service sexual assault occurred until he underwent the May 2006 VA examination in connection with the current VA disability compensation claim. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous statements made for treatment purposes in which he denied being a victim of sexual abuse in March 1993, July 2000, and August 2000. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the veteran's statements, it may consider whether self-interest may be a factor in making such statements). The Board also notes an inconsistency between the Veteran's assertion of in-service combat exposure as he informed the May 2006 VA examiner that he was never in a war zone. These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of a nexus between his claimed disorder and service. See Gardin v. Shinseki, 613 F.3d 1374, 1380 (Fed. Cir. 2010) (upholding Board finding that vague and inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence); Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). In light of the Veteran's lay statements above, the Board has weighed the Veteran's statements as to in-service combat exposure and in-service sexual assault and finds that such statements are internally inconsistent and to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation. The Board also finds there is no credible evidence to corroborate that the claimed in-service assault occurred in light of the Veteran's own inconsistency as discussed above. As a result, the Board finds that the weight of the lay and medical evidence is against a finding of establishing service connection for PTSD under 38 C.F.R. § 3.304(f)(3) or 38 C.F.R. § 3.304(f)(5). Next, service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's acquired psychiatric disorder to active duty, despite his contentions to the contrary. To that end, the Board places significant probative value on May 2006 and August 2010 VA examinations undertaken specifically to address the issue on appeal. In May 2006, the Veteran reported he was raped in service, was never in a war zone, received one disciplinary action for drinking on duty, and held numerous jobs from 1977 to 1984. He left most of these jobs because he was depressed and dissatisfied and denied losing them because of substance abuse although admitted to abusing alcohol and marijuana during that period. He also complained of having trouble eating and sleeping and on and off drinking which made him depressed. After a mental status examination, the examiner noted the Veteran had a long history of abuse and alcohol, starting when entered service and diagnosed recurrent major depressive disorder without psychotic features, alcohol dependent in early full remission, cocaine dependence in early full remission, and cannabis abuse. The examiner opined the diagnosis of major depressive disorder was considered currently to result in moderate impairment in the Veteran's social and occupational functioning. On VA examination in August 2010, the Veteran reported receiving treatment for alcohol and cocaine dependence, which the examiner affirmed after review of the record. The examiner also noted "[t]here is a history of a single diagnosis of PTSD but there is no contextual verification for the diagnosis nor is there any treatment for the diagnosis. Evidently it was a free standing diagnosis given at one point." Following the mental status examination, the examiner diagnosed the Veteran with polysubstance dependence in very early remission and concluded: The [Veteran] does not have symptoms meeting the criteria for diagnosis of PTSD. Although he does have some nightmares about being on the ship, this does not constitute symptoms of PTSD. The [Veteran] said that his sexual trauma is constantly on his mind, yet he has never sought treatment and this does not appear in his medical records as a problem and the medical records are quite extensive for treatment. Furthermore, other symptoms of PTSD also do not appear in the [Veteran's] medical records as presenting problems despite numerous treatments at several different VA Medical Centers. Further, some of the [Veteran's] statements are conflictual with actual behaviors (citing examples) . . . The [Veteran] is not being treated for any other mental health condition except his polysubstance abuse. Prognosis is poor given the [Veteran's] history. A reasonable reading of this opinion is that the Veteran's psychiatric disorders are not related to service. The Board finds that the examinations are adequate for evaluation purposes. Specifically, the examiners reviewed the claims file and electronic medical record, interviewed the Veteran, and conducted a physical examination. There is no indication that the VA examiners were not fully aware of the Veteran's past medical history or misstated any relevant fact. Moreover, the examiners have the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. Further, there is no contradicting medical evidence of record and the Veteran failed to appear for subsequently scheduled VA psychiatric examinations in June 2012 and July 2012. Therefore, the Board finds the VA examiners' opinions to be of great probative value. While the Board reiterates that the Veteran is competent to report symptoms as they come to him through his senses, an acquired psychiatric disorder, to include depression, bipolar disorder, and PTSD, is not the type of disorder that a lay person can provide competent evidence on questions of etiology. Such competent evidence has been provided by the medical personnel who have examined the Veteran during the current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. See Cartright, 2 Vet. App. at 25. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (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; 38 C.F.R. §§ 3.101, 3.156(a), 3.159, 3.326(a). 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This 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). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; and (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) 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 warranted. Id. at 486. Here, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence VA found lacking in the claimant's presentation." Rather, such notice errors may instead 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) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification allowed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial RO decision by way of a letter sent to the Veteran in February 2010 that fully addressed all four notice elements. This letter informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Therefore, he was "provided the content-complying notice to which he [was] entitled." Pelegrini, 18 Vet. App. at 122. Furthermore, the service connection claim was readjudicated, and a supplemental statement of the case was issued in January 2013. Consequently, the Board finds that the duty to notify has been satisfied. With respect to the Dingess requirements, in March 2006 and February 2010 letters, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With those letters, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In determining whether a medical examination be provided or medical opinion obtained, there are four factors to consider: (1) competent evidence of a current disability to persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. With respect to the third factor, the types of evidence that "indicate" that a current disorder "may be associated" with 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). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA inpatient and outpatient treatment records. Next, specific medical opinions pertinent to the issue on appeal were obtained in May 2006 and August 2010. The Board notes that the Veteran was scheduled for additional VA examinations in connection with this claim on appeal in June 2012 and July 2012 and the Veteran failed to appear. Review of the Veteran's claims file on the "Virtual VA" system indicates the Veteran was thereafter incarcerated in state prison in Alabama from August 2012 to February 2013. The Board finds that although the August 2010 VA medical opinion was not rendered after review of subsequent VA outpatient treatment records showing treatment and diagnoses for psychiatric problems, a remand for an additional VA examination would unduly delay resolution. The duty to assist is not a one-way street. Woods v. Gober, 14 Vet. App. 214, 224 (2000); see also Hurd v. West, 13 Vet. App. 449, 452 (2000)(veteran cannot passively wait for help from VA). Thus, VA is not required to provide any more assistance to him with regard to a VA examination as the Veteran did not provide good cause for his absence from the June 2012 and July 2012 scheduled VA examinations, and VA has no further obligations in this regard. Pursuant to the Board's December 2009 remand instructions, the RO obtained and associated with the claims file outstanding VA outpatient treatment records from June 2005 to December 2009. The February 2010 VCAA notice letter was sent to the Veteran, to include regulations for a PTSD claim based on personal assault. He was also asked to provide further information regarding the assault, and to this date, has not provided such information. See Woods, 14 Vet. App. at 224. His personnel records were obtained and associated with the claims file, as well as unit records and information regarding the USS Mayaguez incident in May 1975. Lastly, the RO arranged for a VA examination in August 2010 and the claim was readjudicated in a November 2010 SSOC. Pursuant to the Board's June 2012 remand instructions, the RO sent the Veteran a June 2012 notice letter with a copy of the November 2010 SSOC. The RO obtained and associated with the claims file on the "Virtual VA" system outstanding VA outpatient treatment records from December 2007 to December 2011. Lastly, the RO arranged for VA examinations in June 2012 and July 2012 and readjudicated the claim was readjudicated in a January 2013 SSOC. The Board finds that VA's duty to assist is met. Therefore, all available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist 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). ORDER Service connection for an acquired psychiatric disorder, to include depression, bipolar disorder, and PTSD, is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs