Citation Nr: 1317855 Decision Date: 05/31/13 Archive Date: 06/06/13 DOCKET NO. 05-39 037 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD), anxiety and depression, including as secondary to service-connected disability. 2. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) prior to May 13, 2011. REPRESENTATION Appellant represented by: Michael Steinberg, Esq. ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran had active service from June 1967 to June 1969 including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a regional office (RO) rating decision of November 2004. In April 2009, the Board issued a decision remanding 12 issues to the RO for additional action. The Board's April 2009 decision directed that the claim of service connection for anxiety and depression be adjudicated by the RO as it was separate from the claim for PTSD and had not yet been addressed by the RO. Thereafter, the United States Court of Appeals for Veterans Claims (the Court) found that a claim for service connection for PTSD encompasses all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The RO denied the claim of service connection for anxiety and depression in September 2011. In written argument received at the Board in January 2012, the Veteran's attorney indicated that the Veteran appeals this decision and urges that the psychiatric disabilities should be adjudicated together as they are inextricably intertwined. The April 2012 Board remand recategorized the issue as noted on the title page. In October 2011, the RO issued a rating decision granting service connection for Parkinson's disease with functional impairment of left and right lower extremities, rated as 100 percent disabling from May 13, 2011. The RO also granted service connection for multiple disabilities related to Parkinson's disease, including stooped posture with functional impairment of the right and left upper extremities, as well as special monthly compensation based on loss of use of lower extremities. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. The Veteran has an acquired psychiatric disorder, diagnosed as PTSD and adjustment disorder with anxiety and depression, as a result of active service or as secondary to service-connected disability. 2. Hypertension was not shown in service or within the first post-service year, and is unrelated to service or to a disease or injury of service origin. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, diagnosed as PTSD and adjustment disorder with anxiety and depression, was due to or aggravated by active service or service-connected disability. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. Hypertension was not incurred in or aggravated by military service; nor may the incurrence of hypertension be presumed. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1116, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. 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 submitted by or on behalf of the Veteran. 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). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2008); 38 C.F.R. § 3.159(b) (2008); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his or her possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in June 2004 and August 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letters informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. An April 2006 letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records, post-service private and VA treatment records, and Social Security Administration (SSA) disability records have been associated with the claims file. All identified and available treatment records have been secured. The Board finds that VA has fulfilled its duty to assist in obtaining such records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4) (2012). The Veteran underwent VA examinations in September 2011 and November 2012 in order to obtain information to substantiate the Veteran's claims. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examiners reviewed the Veteran's claims file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for the purpose of rendering a decision in the instant appeal. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, the Board will proceed to a decision on the merits as to the issue on appeal. Acquired Psychiatric Disorder A. Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including psychoses, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2012). This includes disability made chronically worse by service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board observes that the provisions of 38 C.F.R. § 3.310 were amended effective as of October 20, 2006, during the pendency of the instant appeal. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by service-connected one is judged. Although the VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the Veteran to establish a pre-aggravation baseline level of disability for the non-service connected disability before an award of service connection based on aggravation may be made. This had not been the VA's practice and thus suggests that the recent change amounts to a substantive change in the regulation. For this reason and as the Veteran's claim was pending before the regulatory change was made, the Board will consider his claim under the prior version of 38 C.F.R. § 3.310 as it is more favorable to the Veteran. In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word 'chronic.' When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2012). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(1) (2012); see also, 38 U.S.C.A. § 1154(b) (West 2002). Otherwise, the law requires verification of a claimed stressor. Where a determination is made that the Veteran did not 'engage in combat with the enemy,' or the claimed stressor is unrelated to combat, the Veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must include service records or other credible evidence that supports and does not contradict the Veteran's testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). In recent years, the regulations governing PTSD have been amended, effective July 13, 2010. 75 Fed. Reg. 39843-52 (July 13, 2010). Specifically, this amendment eliminates the requirement for corroborating that the claimed in-service stressor occurred if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, provided that the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. Id. B. Analysis The Veteran is claiming entitlement to service connection for a psychiatric disorder, which he contends is due to his military service. Upon induction in June 1967, the Veteran reported a history of occasional anxiety and tension. Despite this reported history, physical examinations dated in June 1967 and June 1969 indicate normal on psychiatric evaluations. In a July 1996 private treatment record, the Veteran complained of depression, anxiety, and nervousness. In a December 2002 private treatment records, the examiner noted that the Veteran's wife complained he was more moody. However, the examiner reported that it is unusual to see testosterone replacement to cause moodiness when most often it actually decreased moodiness and irritability. In various private treatment records dated in June 2003 and July 2004, the examiner noted he was positive for nervousness. In a September 2003 private treatment record, the Veteran denied a history of nervousness. A private treatment record dated in March 2004 indicated a diagnosis of adjustment disorder with anxiety and depression, and PTSD. The Veteran denied any previous mental health treatment except for taking medication while he was hospitalized following a recent heart attack. His concerns were anxiety and stress. He denied recent anxiety and depression. He claims stress related to having served in Vietnam and that recent stress is more problematic. In letters dated in January 2005 and June 2006, I. M., PhD, reported that the Veteran has PTSD related to his experiences in Vietnam. Specifically he had anxiety and fear, persistent dreams and nightmares, avoidance, and increased arousal. In the January 2005 letter, the psychologist reported that he worked for the VA 25 years ago and was a consultant to the Vietnam Veterans Center with experience treating cases of PTSD. A June 2006 VA progress note included a diagnosis of mood disorder. In a March 2011 VA mental health consultation, the Veteran reported he still has effects of PTSD issues yet his main pressing issue is his debilitating illness. Upon mental status examination, the examiner noted that the depression survey, clinical interview, and consultation with the staff revealed that the Veteran is presently experiencing a mild depression and moderate anxiety. He has a history of some PTSD features. The diagnosis was mild adjustment disorder with mixed features. In an August 2011 follow-up, the Veteran complained of increasing anxiety. A VA progress note dated in March 2011 indicated the Veteran as admitted for wound care. Medically, he was generally in good health until last fall; between August and December he became gradually weaker. He was ultimately placed in a community nursing home. The examiner noted the has a long history of vivid nightmares, intrusive recollections, trigger avoidance, exaggerated startle, and some irritability, related to combat service in Vietnam. These symptoms have been worse since his illness has become disabling, both due to his loss of independence and his concern about his wife's well being. The only psychiatric contact was in the private sector about five years prior; he was treated with as needed Xanax which he rarely used. He was started on Zoloft during his recent hospitalization but has declines using this as he feels it has been sedating. The diagnosis was PTSD related to Vietnam combat, now exacerbated by the disabling aspects of his current illness. During a July 2011 VA follow-up, the examiner noted that he continues to do well psychiatrically, and PTSD symptoms are at baseline without problems with anxiety. During a September 2011 VA examination, the examiner reported a diagnosis of an adjustment disorder with anxiety. The examiner considered the letters of the private psychologist and noted that there was no identifiable formal assessment of the PTSD diagnosis and it is unclear why the diagnosis was offered when the intake evaluation indicated "denied anxiety and depression". The VA psychologist found the assessment to be nonprobative given the lack of any diagnostic criteria within it. The follow-up letter by the private psychologist also indicated an opinion without review of the claims file or other medical records. The examiner determined that the assessment was apparently made without a formal assessment of PTSD. After a mental status examination, the examiner found that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner noted that the Veteran's service medical records showed he complained of anxiety at entrance and discharge examination. There was no objective medical record documenting ongoing treatment from the time of his discharge until 2003 when he first complained of mood swings, which were thought to be related to low testosterone. The examiner asserted that although the Veteran was diagnosed by a treating psychologist, the medical records do not support the diagnosis, which seems to have been made based on an unstructured interview with the Veteran. Current research indicates that the use of a structured interview is significantly superior in assessing for PTSD versus an unstructured interview. In this case, the Veteran has maintained that he did not have any problems with anxiety prior to going to Vietnam, but his service medical records clearly show the history of anxiety prior to military service. Not one of the treating providers had access to the Veteran's claims file and service medical records. The examiner noted that although the Veteran was treated for PTSD, this does not necessarily mean he has a diagnosis of PTSD. In an October 2011 rating decision, the RO granted service connection for Parkinson's disease with functional impairment of the left and right lower extremities, including bradykinesia and balance impairment, associated with herbicide exposure, effective May 13, 2011. In a November 2011 statement, the Veteran's representative asserted that the Veteran's anxiety is secondary to his service connected coronary artery disease or that his psychiatric disorder existed at the time of service and was not pre-existing; if it was pre-existing, the Veteran's current psychiatric disorder was aggravated during military service. The RO obtained an additional VA opinion in November 2012. The psychologist opined that the Veteran's claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. The psychologist noted that the Veteran's diagnosis of adjustment disorder with anxiety was based on his having been admitted to the nursing home for other medical issues. The Veteran has a significant number of medical issues and there is no means for determining which of these medical conditions is the primary cause of the Veteran's mental condition without the use of mere speculation. Several of the medical conditions are known to have high co-morbid mental health issues such as depression and anxiety (e.g. Parkinson's disease and testicular carcinoma) and the hypothyroidism, if left untreated or undertreated, can mimic psychiatric symptoms. Given the significant number of health issues the Veteran has, it is at least as likely as not that any pre-existing mental health condition was exacerbated beyond natural progression. There is no means without the use of mere speculation to determine by how much the Veteran's functioning has deteriorated as a result of these conditions and exacerbation of the mental health issues. His premorbid functioning cannot be determined without the use of speculation. There is no means to determine which of the many medical issues or what combination of the medical issues exacerbates his mental health condition. The Veteran is service-connected for Parkinson's disease. It is at least as likely that the Parkinson's disease diagnosis has exacerbated any underlying mental health condition beyond normal progression but the degree of exacerbation cannot be determined without mere speculation. In an April 2013 statement, the Veteran's VA geropsychiatrist noted that the Veteran suffered from severe PTSD related to "combat service" in Vietnam. The psychiatrist noted that the Veteran's disability was characterized by vivid nightmares, intrusive recollections, trigger avoidance, exaggerated startled, irritability and severe anxiety. Further, it was noted that the PTSD and anxiety have been exacerbated by his service-connected Parkinson's disease. The Board finds that entitlement to service connection for an adjustment disorder with anxiety as well as PTSD is warranted. The Veteran's service records reveal that he served in Vietnam. The medical evidence of record reveals that the Veteran has been diagnosed with an adjustment disorder with anxiety. Although a VA examiner in September 2011 rendered the opinion that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD, the examiner did not give an etiology opinion for the Veteran's diagnosed anxiety disorder. The November 2012 VA psychologist found the Veteran had a pre-existing psychiatric disorder that was aggravated by the Veteran's service-connected Parkinson's disease. Likewise, the Veteran's geropsychiatrist noted that PTSD was aggravated by Parkinson's disease. With consideration of the circumstances and events of the Veteran's service, and the clinical evidence of record, with resolution of doubt in the Veteran's favor, the Board finds that the evidence supports entitlement to service connection for an acquired psychiatric disorder to include adjustment disorder with anxiety and PTSD. In closing, the Board again notes that the Veteran originally filed a claim entitlement to service connection specifically for PTSD, and such claim was recharacterized by VA as potentially encompassing other psychiatric diagnosis. In this regard, the Board further notes that it considers the Veteran's original psychiatric disability claim to have been fully granted through the above grant of entitlement to service connection for an acquired psychiatric disorder to include anxiety disorder, not otherwise specified, and PTSD. Hypertension A. Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. See 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 67 Fed. Reg. 42600-42608 (2002). On October 13, 2009, the VA announced a decision to establish presumptive service connection for three conditions, including ischemic heart disease. A proposed rule adding these three conditions to VA's list of presumptive diseases was published in the Federal Register on March 25, 2010, 75 Fed. Reg. 14,391. For purposes of this regulation, the term "ischemic heart disease" includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina. Since the term refers only to heart disease, it does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke. (See Nehmer Training Guide, February 10, 2012) Service connection can be granted for certain diseases, including hypertensive renal disease, if manifest to a compensable degree within one year of separation from active service. Such diseases shall be presumed to have been incurred in service even though there is no evidence of disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that when a claimed disorder is not included as a presumptive disorder direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during the service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. See 38 C.F.R. § 3.102 (2012). B. Analysis The Veteran contends that his hypertension as a result of herbicide exposure in Vietnam. The Veteran's service treatment records, including June 1967 enlistment and June 1969 separation examination reports, are negative for any findings of hypertension. In a March 1968 service treatment record, the Veteran reported that he passed out that morning. His blood pressure read 146/100. The examiner noted an assessment of hypertension. In a July 1996 private urology note, the Veteran denied high or low blood pressure. Private treatment records from Dr. C. dated from December 1999 to August 2003 are negative for findings of hypertension. In an August 2003 private treatment record, the diagnoses included hypertension. In an April 2004 VA progress note, the Veteran reported that he has been aware of a problem of hypertension for approximately one year. He reported that he believes his blood pressure is currently under control and he monitors his blood pressure on a frequent basis. A July 2003 operative report from Brandon Regional Medical Center noted a history of hypertension. At that time, the Veteran underwent a coronary angiography, left ventriculography, left heart catherization, and primary stent placement. In a November 2012 VA opinion, a physician opined that there was less than a 50 percent probability that the Veteran's current hypertension is relate to service. The examiner noted that the Veteran's blood pressure was mildly elevated in March 1968 when he was seen for an injury; however, he observed that an injury or stress can cause transient elevated blood pressure which should return to normal. The examiner observed that there was no evidence of chronicity of the condition noted in service and after active duty. The Veteran's blood pressure at exit interview was normal. The examiner also noted that, as per a cardiology note in April 2004, the Veteran stated he has had hypertension for one year. Based upon the evidence of record, the Board finds hypertension is not shown to have developed as a result of an established event, injury, or disease during active service. Exposure to Agent Orange is conceded in this case, as service personnel records show that the Veteran did serve in the Republic of Vietnam. However, the Veteran's diagnosed hypertension is not an enumerated disease associated with Agent Orange exposure under 38 C.F.R. § 3.309(e) (2012); and, in fact, has recently been specifically excluded as a disease resulting from herbicide exposure. Consequently, the Veteran's claim must be denied on this basis. The regulations governing presumptive service connection for Agent Orange do not, however, preclude a veteran from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (1994). Accordingly, the Board will proceed to evaluate the Veteran's claims under the provisions governing direct service connection, 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303. Having reviewed the complete record, the Board finds that the preponderance of the evidence is against finding that the Veteran's current hypertension was incurred in or caused by his service. Although the claims file included a single finding of elevated blood pressure in 1968, subsequent treatment records and separation examination was normal for any hypertension disorder. Evidence of a chronic high blood pressure was first shown in August 2003, more than 30 years after separation from active service, and cannot be presumed to have occurred in service. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). In adjudicating a claim, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board acknowledges that the Veteran is competent to give evidence about what he experienced. See Layno v. Brown, 6 Vet. App. 465 (1994); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). Competency of evidence, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ('although interest may affect the credibility of testimony, it does not affect competency to testify'). See also Buchanan v. Nicholson, 451 F.3d 1331 (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence.) Here, the only opinion regarding etiology is the November 2012 VA opinion which considered the 1968 service treatment record and found the Veteran's hypertension was not incurred in active service. While he filed a claim for service connection for hypertension, the Veteran made no remarks regarding any symptoms or continuation of symptoms from service to his diagnosis of hypertension. While the Veteran would be competent to provide statements about any symptoms he may have experienced, he would not be able to diagnose hypertension without blood pressure readings. The Board finds the most probative opinion on etiology is the November 2012 VA examiner's opinion which weighs against the claim. For the foregoing reasons, the claim for service connection for hypertension must be denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990). ORDER Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), anxiety and depression, including as secondary to service-connected disability, is granted. Entitlement to service connection for hypertension is denied. REMAND Unfortunately, the Board finds that an additional remand is necessary prior to adjudication of the Veteran's TDIU claim. A TDIU may be assigned even where the combined rating for the veteran's service-connected disabilities is less than total if the disabled veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). As noted previously, in an October 2011 decision, the RO granted service connection for Parkinson's disease and associated secondary disabilities and assigned a total schedular rating effective May 13, 2011. Prior to May 13, 2011, the Veteran's only service connected disorder was coronary artery disease with an assigned disability rating of 30 percent. At 30 percent, the Veteran does not meet the disability rating for a TDIU. However, the Board has granted service connection for an acquired psychiatric disorder and the RO will need to determine the effective date and proper rating for that disorder, which may raise the Veteran's combined disability rating. The Board finds that after the appropriate disability rating and effective date for service connection for an acquired psychiatric disorder is established, the RO should re-evaluate the Veteran's claim for TDIU based on all service-connected disorders prior to May 13, 2011. Accordingly, the case is REMANDED for the following action: 1. The RO should assign a disability rating and effective date for the Veteran's service-connected acquired psychiatric disability. 2. After completion of the above, and any other development deemed warranted by the record, the RO should adjudicate the claim on appeal in light of all pertinent evidence (to specifically include all that added to the record since the issuance of the last SSOC on the matters on appeal) and legal authority. The RO must provide adequate reasons and bases for its determinations. 3. If the benefit sought on appeal remains denied, the RO should furnish to the Veteran and his representative an appropriate supplemental statement of the case (SSOC), and afford them the opportunity to provide written or other argument in response thereto before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs