Citation Nr: 1317541 Decision Date: 05/29/13 Archive Date: 06/06/13 DOCKET NO. 10-47 340 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), adjustment disorder, depressive disorder and bipolar disorder. REPRESENTATION Veteran represented by: Virginia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and Ms. BD ATTORNEY FOR THE BOARD V. Chiappetta, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from June 1980 to July 1983. This matter is before the Board of Veterans' Appeals (the Board) on appeal of a March 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which denied Veteran's service connection claims for PTSD and a low back disability. The Veteran testified at a Travel Board hearing which was chaired by the undersigned Veterans Law Judge at the Roanoke RO in August 2011. A transcript of the hearing has been associated with the Veteran's VA claims folder. In a June 2012 decision, the Board expanded the Veteran's PTSD claim to include consideration of whether service connection may be warranted for any psychiatric disability, as per the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board then remanded the Veteran's appeal for additional evidentiary development. Such was achieved, and the Appeals Management Center (AMC) readjudicated the Veteran's claims in an April 2013 Supplemental Statement of the Case (SSOC). The Veteran's claims file has been returned to the Board for further appellate review. 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). (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. The evidence of record is against a finding that a relationship exists between the Veteran's currently diagnosed low back disability and his period of active duty military service. 2. The evidence of record is against a finding that a relationship exists between the Veteran's currently diagnosed acquired psychiatric disability and his period of active duty military service. CONCLUSIONS OF LAW 1. The Veteran's current low back disability was not incurred in or aggravated by his active duty military service. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309 (2012). 2. The Veteran's current acquired psychiatric disability was not incurred in or aggravated by his active duty military service. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Stegall concerns As noted above, the Board remanded the Veteran's appeal in June 2012 for additional evidentiary development. In particular, the Board instructed the AMC to obtain all VA treatment records relevant to the Veteran's psychiatric treatment dating from March 2010 to the present, to schedule the Veteran a VA psychiatric and spine examinations to determine the nature and etiology of any respective diagnosed depression and low back disability, and to readjudicate the claims. In compliance with the Board's instructions, the AMC requested the Veteran's updated VA treatment records from the Hampton VA Medical Center dating from March 2010, and associated them with the Veteran's electronic claims file. The Veteran also appeared for VA psychiatric and spine examinations in August 2012. The corresponding examination reports have also been associated with the claims file. The AMC subsequently readjudicated the Veteran's claims in the above-referenced April 2013 SSOC. Thus, the Board's remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant claim. The VCAA provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VCAA also requires VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also notes that the United States Court of Appeals for Veterans Claims (the Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided the Veteran with adequate notice under the VCAA and Dingess specific to his service-connection claims in a November 2009 letter. Subsequently, in March 2010, the RO adjudicated these claims in the first instance, and the Veteran filed a timely appeal as to the RO's determinations. Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with the issuance of a decision on the merits as to these claims. Concerning the VA's duty to assist, the Board notes that the Veteran's relevant post-service VA and private treatment records, records from the Social Security Administration, and his own lay statements have been obtained. Neither the Veteran nor his representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. With respect to the VA examinations conducted in conjunction with this appeal, the Board observes that the current findings contained therein are more than adequate to adjudicate the Veteran's service-connection claims. Indeed, the Veteran appeared for VA spine and psychiatric examinations in August 2012, and the corresponding examination reports are of record. Notably, both VA examiners indicated that they reviewed the Veteran's prior records in conjunction with their performance of the VA examinations. In addition, the examination reports reflect that each examiner was aware of the Veteran's pertinent medical history, recorded the Veteran's current complaints, conducted an appropriate examination, and rendered appropriate findings and diagnoses consistent with the other evidence of record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions concerning the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). Finally, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The undersigned set forth the issues to be discussed at the August 2011 hearing and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. He also specifically focused on the elements necessary to substantiate the claims, to include the need for a nexus opinion linking the Veteran's current disabilities to his service. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that consistent with Bryant, there is compliance with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of the Veteran's claims has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the issue on appeal were nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claim. See 38 C.F.R. § 3.103. He has retained the services of a representative, and presented testimony before the undersigned at a personal hearing. Accordingly, the Board will address the issues on appeal below. Law and analysis In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection also may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a claimant 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For certain chronic disabilities identified under 38 C.F.R. § 3.309(a), such as arthritis or a psychosis, direct service connection may alternatively be established based on a finding of continuity of symptomatology. See 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). In addition, service connection for arthritis or a psychosis may also be granted if such disabilities becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). A. Low back disability In essence, the Veteran contends that he has a current low back disability that is directly related to an injury sustained in an in-service motor vehicle accident. The Board notes at the outset that it is undisputed that the Veteran has a current lumbar spine disability-namely lumbar degenerative disc disease with arthritis. See the August 2012 VA examiner's report, at 1 and 10. Thus, Shedden element (1), present disability, is satisfied. With respect to Shedden element (2), in-service injury or disease, the Veteran's service treatment records clearly note that the Veteran was involved in a motor vehicle accident in October 1982. Specifically, the Veteran was thrown from a jeep, and the jeep rolled over his lower abdomen, pelvis, and left wrist. The Veteran was hospitalized and sustained fractures of his pelvis and left wrist. He has since testified that he also injured his back in the accident, and that he has experienced continued low back pain from the date of the accident to the present day. See the August 2011 hearing transcript, at 8. The Veteran is certainly competent to attest to his own observable symptoms and experiences, to include having experienced back pain following his October 1982 motor vehicle accident. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). Although the Veteran's service records include no documentation of any in-service complaints of low back pain, the Board finds nothing in the record to call into question the Veteran's report that he sustained an injury to the back in this documented in-service accident. Indeed, the August 2012 VA examiner has conceded the fact that this in-service injury occurred, noting that the Veteran sustained a "lumbar strain" in 1982. See the August 2012 VA examiner's report, at 1. Thus, in light of the Veteran's competent and credible statements as to his in-service back problems, coupled with the documented motor vehicle accident and the recent assessment of the August 2012 VA examiner, the Board finds that in-service injury is demonstrated by the record, and that Shedden element (2) is satisfied as well. The Board notes at this time that there is no evidence of record, lay or medical, suggesting that the Veteran developed arthritis of the lumbar spine within the one year presumptive period following his separation from service in 1983. Thus, service connection for his current disability is not warranted on a presumptive basis under the provisions of 38 C.F.R. § 3.307 and 3.309(a). With respect to crucial Shedden element (3), nexus or relationship, there are only two medical opinions of record addressing whether a relationship exists between the Veteran's current low back disability and his in-service injury. In September 2010, a fee-based QTC examiner reviewed the Veteran's prior history, examined the Veteran's spine, and determined it was less likely as not that the Veteran's current disability was related to his in-service motor vehicle accident. Significantly however, the Board has already determined that the September 2010 QTC examiner's negative nexus opinion is inadequate for adjudicatory purposes, as it relied extensively on a lack of medical documentation of treatment in the record, and appeared to disregard the Veteran's lay statements of history regarding in-service back pain and ongoing symptoms. See the Board's June 2012 decision, at 3; see also Nieves-Rodriguez, 22 Vet. App. 295 (2008); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007), Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). As such, the Board instructed that a new examination and medical opinion be obtained. In August 2012, the Veteran appeared for his second spine examination. After review of the record and upon examination of the Veteran, the August 2012 VA examiner also concluded that it is less likely as not that the Veteran's low back disability was caused by, or a result of his in-service accident. Unlike the September 2010 QTC examiner however, the August 2012 VA examiner did consider the Veteran's lay assertions of having sustained an in-service back injury, and crucially formulated his opinion on the same premise the Board accepts as true herein-namely, that the Veteran did in fact injure his low back during service. As noted above, the August 2012 VA examiner specifically diagnosed the Veteran with an in-service lumbar strain on page 1 of his examination report. In support of his opinion, the VA examiner acknowledged the lay assertions of in-service pain from the Veteran and his fiancée, but determined that a relationship between the Veteran's current disability and service did not exist based on a multitude of factors, to include the fact that the Veteran was able to stay in service doing the same job for a year after the accident, that his in-service hospital reports noted no back problems, that he did not seek medical attention for decades after service until 2009, and that he was able to work two years as a construction worker and four years as a plumber after service. The Board recognizes that the August 2012 VA examiner referenced the Veteran's normal lumbar spine x-ray reports dated in June 1982 [predating the Veteran's October 1982 accident] in his rationale, but finds that any reliance on these pre-injury reports in formulating a negative nexus opinion does not render the opinion inadequate for adjudicatory purposes, as multiple other supportive reasons for the negative opinion were also provided. There is no medical opinion of record that is contrary to that of the August 2012 VA examiner. The Veteran has been accorded ample opportunity to furnish medical evidence in support of his claim, and against the above-described conclusions of the August 2012 VA examiner, but he has not done so. See 38 U.S.C.A. § 5107(a) (noting that it is a claimant's responsibility to support a claim for VA benefits). The Board recognizes that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Crucially however, the resolution of the key issue in this case-namely, whether the Veteran's lumbar degenerative disc disease with arthritis is related to active duty service-falls outside the realm of common knowledge of a lay person. Cf. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). The record does not reflect that the Veteran has had the education, training, or experience to qualify him to offer medical opinions, such as the etiology of lumbar degenerative disc disease with arthritis. 38 C.F.R. § 3.159(a)(1) (2012); see also DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 149 (30th ed. 2003) (defining "arthritis" as "inflammation of a joint"). The Board notes that arthritis is a disability specifically characterized as a "chronic disease" under 38 C.F.R. § 3.309(a). As such, entitlement to service connection may still be established by a showing of continuity of symptoms, as per 38 C.F.R. § 3.303(b) described above. See Walker, 708 F.3d at 1338-39. In this connection, the Veteran has indeed asserted that his low back pain initiated in service and has been continuous to the present day. As noted above, the Veteran is certainly competent to report observable continuous low back symptomatology existing since service. Competency of evidence, however, differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter 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"). The Court has made clear that the Board cannot determine that competent lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this case however, while it is true that the Veteran sought no treatment for any back problems until 2009, the Board finds it much more significant that when he finally did seek treatment, he specifically reported that his back pain actually began in 1998, well over a decade after his separation from service in 1983. See the Veteran's August 31, 2009 Primary Care Provider Note. Indeed, the Veteran stated at this 2009 assessment that he has had chronic low back pain for eleven years since working as a painter climbing on a stair ladder, and specifically denied any prior fall or trauma. In light that the Veteran has provided contradictory histories to VA physicians for treatment purposes in 2009, and subsequently provided to VA for compensation purposes shortly thereafter, the Board finds the Veteran's assertions of continuity of symptoms simply not credible. See Caluza v. Brown, 7 Vet. App. 498 (1995) (in determining whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of a veteran); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Based on the Veteran's inconsistent reporting of his own medical history, coupled with the reasoned medical opinion evidence of record suggesting that the Veteran's current low back disability is unrelated to his in-service injury, the Board finds that the evidence of record is against a finding of continuity of symptoms since service. Shedden element (3) remains unsatisfied, and the Veteran's service-connection claim fails on this basis. The benefit-of the-doubt rule is not for application because the evidence is not in relative equipoise. B. Acquired psychiatric disability The Veteran asserts that he has a current psychiatric disability that is related to his period of active duty service. In particular, the Veteran claims that stressful experiences occurring during service, to include his October 1982 motor vehicle accident, caused him to develop a mental disorder. The evidence of record, to include copies of the Veteran's ongoing VA treatment records uploaded into his electronic claims folder, demonstrates that the Veteran was diagnosed with adjustment disorder, depressive disorder with psychotic features, and bipolar disorder at various times during this appeal period. At his most recent mental health examination, an August 2012 VA examiner specifically diagnosed the Veteran with recurrent major depressive disorder. See the August 2012 VA examiner's report, at 1. Thus, Shedden element (1), present disability, is satisfied. Although the Veteran has also been diagnosed with alcohol and drug dependence, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that 38 U.S.C.A. § 105 and § 1110 preclude compensation for primary alcohol abuse disabilities and secondary disabilities that result from primary alcohol abuse. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). The decision explains that "primary alcohol abuse" means an alcohol abuse disability arising during service from voluntary and willful drinking to excess. Id. However, the Federal Circuit has held that service connection is warranted when drug or alcohol abuse results secondarily from a service-connected disability, but compensation should only result "where there is clear medical evidence establishing that the drug or alcohol abuse disability is indeed caused by the veteran's primary service-connected disability." Id. at 1371, 1381. Thus, to the extent the Veteran's current appeal includes a request for compensation for his alcohol and drug dependencies, the Board wishes to make clear that compensation for such dependencies may only be awarded if they are related to an underlying service-connected mental illness. In this case therefore, the threshold question at issue is whether any current psychiatric condition other than his alcohol and drug dependencies may be directly related to the Veteran's service. The Veteran also asserts that he has PTSD. In support of his claim, he has submitted one VA treatment record that in fact includes an Axis I PTSD diagnosis in addition to diagnoses of major depressive disorder with psychotic features and alcohol dependence. See the Veteran's June 8, 2010 VA Mental Health Physician Note. The Board notes that this June 2010 diagnosis of PTSD from VA psychiatrist W.W.M. marks the only instance during the appeal period where PTSD is diagnosed. Indeed, no VA examiner has diagnosed PTSD, and the Veteran's prior PTSD screens have been negative. See, e.g., the September 2010 QTC fee-based examiner's report, at 6 (specifically noting that the Veteran does not endorse all of the requisite symptoms of PTSD); see also the Veteran's August 31, 2009 VA Nursing Outpatient Note (indicating a negative PTSD screen). In fact, just two months after including this PTSD diagnosis under the Veteran's list of Axis I disorders, the same VA psychiatrist, W.W.M., specifically ruled the diagnosis out. See the Veteran's August 25, 2010 VA treatment report. The Board accordingly finds that the evidence of record weighs substantially against a finding that the Veteran has PTSD, as the only mental health professional who did in fact diagnosis the disability in June 2010 specifically ruled it out two months later. As noted above, the other medical evidence of record clearly demonstrates diagnoses of other psychiatric conditions to include adjustment disorder, depression and bipolar disorder. Moving next to Shedden element (2), in-service disease or injury, the Board notes that the Veteran's service treatment records include no complaints of, treatment for or diagnoses of any mental health disability, and the Veteran does not contend that he sought treatment for any mental health problems in service. Further, there is no evidence of record, lay or medical, suggesting that the Veteran developed a psychosis within the one year presumptive period following his separation from service in 1983, as per the provisions of 38 C.F.R. § 3.307 and 3.309(a). As noted above however, the Veteran does assert that certain stressful events experienced during his period of active service, to include his October 1982 motor vehicle accident, ultimately caused him to develop his current mental health problems. As discussed in detail above, it is undisputed that this accident occurred, as his service records document the nature of the accident and the subsequent treatment he received for his physical injuries. In so far as the Veteran relates his current disability to this documented in-service stressful event, the Board finds that Shedden element (2), in-service injury, is also satisfied. Further, however, although there is opinion evidence (outlined below) that discusses the presence of psychiatric symptoms in the Veteran's years prior to service, the Veteran's own assertions coupled with the evidence contained in the service treatment records demonstrate that the Veteran did not have a psychiatric disability while in service, but rather only experienced in-service injury of stressors. There is no evidence that a psychiatric disability began while the Veteran was still in service. The Board notes that at times during the appeal period, the Veteran also indicated to VA physicians that while on active duty, he witnessed the accidental shooting of a friend and watched another soldier fall to his death when his parachute did not open. While reports of these events are not documented in the record, the Board notes that the medical opinion evidence discussed immediately below demonstrates that VA physicians were in fact aware of the Veteran's competent recollections of these in-service events in addition to his documented motor vehicle accident, and considered them when rendering diagnoses and opinions. See the September 2010 QTC fee-based examiner's report, at 1 and 2; see also the August 2012 VA examiner's report, at 7. In this connection, with respect to crucial Shedden element (3), nexus or relationship, there are only two medical opinions of record addressing the etiology of the Veteran's current psychiatric disabilities. In September 2010, the above-referenced QTC fee-based examiner determined that the Veteran's psychiatric disability [diagnosed as adjustment disorder with depressed mood] was result of being "physically abused by his father, financial stress, difficulty holding a job, unemployment since 2009 after his medical doctor ordered him to stop working, the troubled relationship with his former girlfriend, the aftermath of the accident in 1982 and his poor work history." See the September 2010 QTC fee-based examiner's report at 6. The examiner offered minimal clinical explanation as to how the Veteran's 1982 accident caused or contributed to his medical disability, noting only that symptoms such as difficulty falling and remaining asleep, irritability and difficulty concentrating were "a result of exposure to traumatic events and as a result of his depression." Id., at 8 and 9. Indeed, the Board finds the September 2010 examiner's conclusions and rationale to be inadequate for adjudicatory purposes, as it appears on the one hand the examiner, at least in part, attributed the Veteran's actual depression disability to his in-service 1982 accident, but on the other, attributed just a few symptoms of sleeping problems, concentration problems and irritability to unspecified "traumatic events," as well as to the overall effects of a depression disability. The September 2010 QTC examiner's assessment leaves it unclear whether the Veteran's current disability was as likely as not caused by his in-service traumas, or whether his disability in and of itself, or in concert with the in-service traumas, merely causes the Veteran to develop a few troubling behaviors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that a medical opinion that contains only data and conclusions is not entitled to any probative value; there must be factually accurate, fully articulated, sound reasons for the conclusion). As such, the Board remanded the Veteran's claim in June 2012 for another medical opinion. As noted above, the Veteran appeared for a VA psychiatric examination in August 2012. Upon review of the evidence of record, and after examination of the Veteran, the August 2012 examiner determined that it was less likely as not that the Veteran's current psychiatric disability was incurred in service, or caused by his claimed in-service traumas, but rather was attributable to a "chaotic upbringing and chronic instances of being the victim of physical/verbal/emotional abuse in this home." The examiner observed that there appeared to be a "significant history of psychiatric dysfunction prior to military service" based on the Veteran's own reported history of mood dysfunction, substance abuse/dependence, and behavioral difficulties during his adolescence. The examiner noted that the Veteran endorsed significant impairment in functioning as a result of these experiences and highlighted the fact that the Veteran joined the military in order to escape such difficulties. In conclusion, the examiner determined that it is more likely that the Veteran's depression is "etiologically linked to his childhood history of victimization/abuse by his stepfather," and that he "established a pattern of symptomatic presentation that followed him into adulthood both during and after his time in service." See the August 2012 VA examiner's report, at 9-10. Significantly, in addition to clarifying the etiology of the Veteran's current disability with a cogent supporting rationale as shown above, the examiner specifically addressed the effects of Veteran's claimed in-service traumas, to include the death of a friend and his motor vehicle accident, noting that the Veteran's self-reported difficulty making friends and sadness about their death had more to do with losing a number of friends over the course of his lifespan, and not specifically the death of anyone in service. With respect to the motor vehicle accident, although the Veteran indicated that the incident keeps him from driving and makes him depressed, the examiner observed that the Veteran did drive during the intervening 28 to 29 years following service, and noted it was unclear why he would more recently develop discomfort behind the wheel of a vehicle. See id., at 9. Indeed, on a functioning report submitted to the SSA for disability benefits in November 2009, the Veteran specifically indicated that he is unable to drive not because of his stressful in-service accident, but because of the medications he is on for his low back disability. See the Veteran's November 18, 2009 SSA Functioning Report, Section D (indicating that he is "unable to even drive a truck because I am on narcotics and it would be very unsafe"). The Board accordingly finds the opinion of the August 2012 VA examiner to be far more probative than September 2010 QTC fee-based examiner, as it is fully explained with a clear and cogent rationale, and specifically addresses each of the Veteran's contentions without circular analysis. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the health care provider to provide a basis for his/her opinion goes to the weight or credibility of the evidence). As above, although lay persons are competent to provide opinions on some medical issues [see Kahana, 24 Vet. App. at 435], the resolution of the key issue in this case-namely, whether the Veteran's acquired psychiatric disability is related to active duty service-falls outside the realm of common knowledge of a lay person. Cf. Jandreau, 492 F.3d at 1377. The record does not reflect that the Veteran has had the education, training, or experience to qualify him to offer medical opinions, such as the etiology of his psychiatric disability. See 38 C.F.R. § 3.159(a)(1) (2012). To the extent the Veteran's current disability picture included a psychotic component at times during the appeal period, the Board notes that psychoses are specifically characterized as a "chronic diseases" under 38 C.F.R. § 3.309(a). As such, entitlement to service connection may still be established by a showing of continuity of symptoms, as per 38 C.F.R. § 3.303(b) described above. See Walker, 708 F.3d at 1338-39. In this case however, the Veteran does not assert that he has experienced continuous psychotic symptoms since his discharge from active duty service in 1983. Rather, the Veteran's specifically reported that his major depression with psychotic features began in April 2010. See the Veteran's SSA Disability Report. When he first started receiving treatment from VA for his mental health problems, he also specifically denied a history of mental health problems or treatment. See the Veteran's July 28, 2009 VA Homeless Program Note. Thus, in light of the probative medical opinion evidence discussed above, the Board finds that a relationship between the Veteran's current psychiatric disability and his active duty service is not established. Shedden element (3) remains unsatisfied, and the Veteran's service-connection claim fails on this basis. As above, the benefit-of the-doubt rule is not for application because the evidence is not in relative equipoise. (CONTINUED ON NEXT PAGE) ORDER Service connection for a low back disability is denied. Service connection for an acquired psychiatric disability, to include PTSD, adjustment disorder, depressive disorder, and bipolar disorder is denied. ____________________________________________ Nathanial J. Doan Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs