Citation Nr: 1318504 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 07-12 999 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Michel, Associate Counsel INTRODUCTION The Veteran (appellant) had active service from July 1965 to November 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, that denied the benefit sought on appeal. The Veteran appealed that decision and the case was referred to the Board for appellate review. In his substantive appeal (VA Form 9) in April 2007, the Veteran requested a hearing before a Veterans Law Judge (VLJ). However, in July 2007, the Veteran's representative advised the Board that the Veteran wished to withdraw that request. Accordingly, the Veteran's request has been withdrawn. 38 C.F.R. § 20.704(e) (2012). When this case was most recently before the Board in December 2012, it was decided in part and remanded in part for additional development. The Board is satisfied that there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The case has been returned to the Board and is ready for further review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT The record does not contain competent medical evidence establishing a diagnosis of PTSD based on an in-service traumatic event or stressor or a diagnosis by a VA psychologist or psychiatrist based on a fear of hostile military or terrorist action; a psychosis was not shown within one year of separation from service; and the weight of the competent medical evidence is against finding a nexus between the post-service diagnosis of any psychiatric disorder and service. CONCLUSION OF LAW An acquired psychiatric disorder, to include PTSD, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1111, 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in a letter dated in October 2005, prior to the issuance of the rating decision on appeal, and again in March 2006 per Dingess. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, outstanding, relevant, available evidence. VA has obtained examinations and medical opinions. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Legal Criteria Service connection may be established for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303, 3.304 (2012). Disability which is proximately due to or the result of a disease or injury incurred in or aggravated by service will also be service-connected. 38 C.F.R. § 3.310 (2012). Service connection may also be established for certain chronic diseases manifested to a compensable degree within a presumptive period following separation from service. 38 C.F.R. §§ 3.307, 3.309 (2012). Psychoses are chronic diseases with a presumptive period of one year. 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated by service. That may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a) (2012). For the showing of 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Service connection may also be warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). A Veteran is presumed to be in sound condition when on entrance into military service except for conditions noted on the entrance examination. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304 (2012). When a condition is properly found to have been pre-existing, the presumption of aggravation provides that a pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002), 38 C.F.R. § 3.306(a) (2012). Aggravation may not be conceded where the disability underwent no increase in severity during service, on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). Service connection for posttraumatic stress disorder (PTSD) requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (under the criteria of DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2012). VA considers diagnoses of mental disorders in accordance with the American Psychiatric Association : The DSM-IV criteria for a diagnosis of PTSD include: A) exposure to a traumatic event; B) the traumatic event is persistently experienced in one or more ways; C) persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness is indicated by at least three of seven symptoms; D) persistent symptoms of increased arousal are reflected by at least two of five symptoms; E) the duration of the disturbance must be more than one month; and F) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). According to the DSM-IV criteria, the traumatic event, or stressor, must involve experiencing, witnessing, or being confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. In addition, the response must involve intense feelings of fear, hopelessness, or horror. 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 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. 38 C.F.R. § 3.304(f) (2012). When the evidence does not establish that a Veteran is a combat Veteran, his assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his alleged service stressors must be established by official service record or other credible supporting evidence. 38 C.F.R. § 3.304(f) (2012); Pentecost v. Principi, 16 Vet. App. 124 (2002); Fossie v. West, 12 Vet. App. 1 (1998); Cohen v. Brown, 10 Vet. App. 128 (1997); Doran v. Brown, 6 Vet. App. 283 (1994). 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, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 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) (2012). Personality disorders are not diseases or injuries under VA regulations. 38 C.F.R. § 3.303(c) (2012). Nevertheless, service connection may be granted if the evidence shows that a psychiatric disability was incurred or aggravated in service and superimposed upon the pre-existing personality disorder. 38 C.F.R. §§ 4.9; 4.125(a), 4.127 (2012); Carpenter v. Brown, 8 Vet. App, 240 (1995); Beno v. Principi, 3 Vet. App. 439 (1992). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. Background Information The Veteran seeks service connection for an acquired psychiatric disorder to include PTSD. In his August 2005 PTSD Questionnaire, and throughout the record, the Veteran has indicated that he was subjected to gas during service and was forced to remove his gas mask. He stated that this has caused him significant psychological and physical problems. The Board notes that servicemembers are typically subjected to tear gas during training. Accordingly, the Board finds it likely that the Veteran was subjected to tear gas in service and thus this claimed stressor is deemed verified. The Veteran's service treatment records show that in July 1966, he was found to have psychophysiological respiratory reaction. In August 1966, he was found to have a passive/aggressive personality. In October 1966, he was hospitalized and found to be passive/aggressive. There was no evidence of psychosis; psychophysiological respiratory reaction, existed prior to service and not aggravated by service, was diagnosed. In 1972 the Veteran was hospitalized for hysterical personality. He was examined by VA in June 1972 and personality disorder, passive aggressive and hysterical type, was the diagnosis. Private records show that the Veteran was seen in May 1991 for what he described as job-related stress, and diagnosed with a psychotic disorder, schizophrenic disorder, schizoaffective disorder and obsessive-compulsive personality disorder. In June 1991 in follow-up, he was diagnosed with a psychotic disorder. Treatment continued into 1992. In July 1992 he was diagnosed with a psychotic disorder characterized as schizophrenic disorder, paranoid type, and atypical psychosis. In December 1996 the Veteran was afforded a VA examination in which the diagnosis was paranoia. The Veteran was found to have PTSD in June 1999, due to a physical assault in January 1999. A private examination by J.C.M., L.C.S.W., showed a diagnosis of PTSD. J.C.M. submitted correspondence in February 2000 in which he stated that he had the occasion to meet with the Veteran in June 1999 and subsequently followed him on a monthly basis; the Veteran carried a diagnosis of paranoia and more recently PTSD following a physical assault in January 1999. Subsequent private and VA treatment records show continuing treatment for various psychiatric complaints into the 2000's. In March 2006 the diagnosis was PTSD due to non-combat military-related exposure to tear gas as based upon subjective history provided to the examiner. In September 2006, the Veteran was seen at a VA outpatient clinic and PTSD, military related, was among the diagnoses. In October 2006 treatment notes, it was stated that the Veteran did not meet the DSM-IV criterion for military related PTSD and more likely met the diagnostic criterion for paranoid schizophrenia. Diagnoses during treatment included chronic paranoid schizophrenia; PTSD, military related/non-combat; and depression. Ms. K.C., R.N., submitted a letter in December 2006 that the Veteran's mental illness appeared to have started prior to his medical discharge from service and that she told him to seek assistance from his service representative and request reconsideration of his case. The Veteran was afforded a VA examination in March 2007 in which he reported serving in the Vietnam era but never served in a combat zone. The examiner diagnosed schizophrenia, chronic, paranoid type. The examiner opined that the Veteran's current psychiatric symptoms were not the same as those noted while he was in service, and he did not have any aggravation of a pre-existing passive aggressive personality disorder. In pertinent part the examiner stated that the Veteran did not have a military experience that would qualify for the Criterion A of PTSD; the Veteran did not currently have the psychiatric disorder that he had in service. The examiner stated that the Veteran did not have a psychotic diagnosis until 1972, six years after service, so there was no close temporal association with his time in service and his schizophrenia diagnosis. The examiner also opined that there was no evidence that the Veteran's personality disorder/s were aggravated by military service; he may have PTSD related to a trauma he suffered as a civilian when he was working as a convenience clerk in a gas stated and was shot in the foot; however, the Veteran did not mention the incident or his "PTSD" symptoms until the examiner mentioned it. The Veteran was examined by VA in April 2011. The claims file was reviewed. The examiner stated that the Veteran's presentations in service predominately met the criteria for hypochondriasis. He referred to notations in the records to support this finding. The examiner stated that he concurred with the finding in service that the disorder had its onset prior to entry into service, has progressed at no greater than usual rate for such disorders. It was stated that the disorder met the DSM-IV criteria for hypochondriasis. The examiner noted that post-service medical evidence began in 1972, and after a long gap, treatment was noted in 1991. He stated that in 1991 the Veteran appeared to have a psychotic episode. Discussion of continuing treatment in the record was noted. The April 2011 examiner reported that the Veteran had pre-military hypochondriasis with poor insights. He reported that he concurred with the conclusion that the disorder had its onset prior to entry in service, had progressed at no greater than the usual rate for such disorders, and that therefore it was considered not aggravated by service. He stated that the Veteran had psychosis that began post-military especially since 1991. He reported that the Veteran's history suggested the presence of a psychotic disorder but that he was unable to determine if it was an exacerbation of pre-morbid hypochondriasis due to psychosocial stressors or evolution of an organized delusional disorder, mixed type, from worsening of hypochondriasis or schizophrenia or interlaced psychotic disorder, hypochondriasis and mixed personality disorder, or all of the above. The Board found that the April 2011 opinion was inadequate for adjudication purposes and remanded the case in December 2012. In response to the Board's remand, an addendum opinion was obtained in January 2013 in which the examiner opined 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 stated that the Veteran clearly and unmistakably had hypochondriasis (with somatization and conversion features) and mixed (histrionic, paranoid, schizotypal, dependent, and obsessive-compulsive) personality disorder prior to service. The examiner stated that the Veteran underwent a series of extensive medical evaluations during this service time; therefore, it was less likely that the exact onset, nature, and course of his psychiatric illnesses were missed or misdiagnosed during service. The examiner generally stated that the evidence of record showed persuasive evidence in support of the noted disorders (hypochondriasis and mixed personality disorder) clearly and unmistakably not aggravated beyond their natural progression by an in-service injury, event, or illness. There was no persuasive evidence in support of PTSD from service. Analysis Initially, the Board notes that the Veteran's enlistment examination in July 1965 shows that he was found to be psychiatrically normal on clinical evaluation. Thus, an acquired psychiatric disorder was not noted when the Veteran entered active duty, and the presumption of soundness applies. Next, the Board must determine whether, under 38 U.S.C.A § 1111 and 38 C.F.R. § 3.304(b), the presumption of soundness is rebutted by clear and unmistakable evidence that the claimed acquired psychiatric disability existed prior to service and was not aggravated therein. In service the Veteran was found to have passive-aggressive personality. Personality disorders are not diseases or injuries for compensation purposes, and disability resulting from them may not be service connected. 38 C.F.R. §§ 3.303(c), 4.127 (2012). That is so because they are considered to be defects of congenital or developmental origin and, by their very nature, pre-exist service. 38 C.F.R. § 3.303(c) (2012). Moreover, congenital or developmental defects are normally static conditions which, unlike diseases, are incapable of improvement or deterioration. VAOPGCPREC 67-90 (1990), 55 Fed. Reg. 43253 (1990). The April 2011 VA examiner also found that the Veteran's hypochondriasis had its onset prior to entry in service. Therefore, the Board finds there is clear and unmistakable evidence that the Veteran's personality disorder and hypochondriasis existed prior to service. Next, the Board must determine whether the Veteran's pre-existing personality disorder and hypochondriasis were aggravated, or incurred a permanent increase in the underlying disability which was not natural progress, during service. The April 2011 examiner stated that the evidence of record showed persuasive evidence in support of the noted disorders (hypochondriasis and mixed personality disorder) clearly and unmistakably not aggravated beyond their natural progression by an in-service injury, event, or illness. Service treatment records do not indicate aggravation of these disabilities as continued treatment was not noted. The Board again notes that any worsening of the Veteran's personality disorder during service does not support the grant of service connection because a personality disorder is not a disability under VA regulations. 38 C.F.R. § 3.303 (a) (2012). Moreover, the Board has determined that the Veteran's personality disorder was not aggravated by a superimposed disability that was incurred during military service as there is no medical evidence or opinion to support this notion. To the extent that the Veteran may claim continuity of psychiatric symptomatology since service, the Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, can be competent, despite the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). 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. Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert, 1 Vet. App. 49. The Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). However, the Board finds that the Veteran's contentions are not credible because the credibility of his subjective history has been questioned by his treatment providers and VA examiners, and has been found to be inconsistent. To this point, the Veteran claimed that he had combat experience and later stated that he did not. Moreover, the March 2007 examiner noted that the Veteran did not mentioned PTSD symptoms until asked. Initially, there is no evidence of psychiatric symptoms or a psychiatric disorder until approximately May 1991 for what the Veteran described as job-related stress, and was diagnosed with a psychotic disorder, schizophrenic disorder, schizoaffective disorder and obsessive-compulsive personality disorder. Prior to that time, there is no evidence of functional impairment due to a psychiatric disability. Therefore, the Board finds that continuity of symptomatology has not here been established, either through the competent evidence or through the Veteran's statements, because the Veteran's statements are not considered credible. A diagnosis of a psychiatric disability was first shown by the evidence of record more than one year after service discharge and the Board finds that the evidence does not show that any psychosis manifested to a compensable degree within one year following separation from service. Therefore, presumptive service connection must be denied. 38 C.F.R. §§ 3.307, 3.309 (2012). The length of time between his separation from service and the initial confirmed clinical diagnosis weighs against continuity of symptomatology. 38 C.F.R. § 3.303(b) (2012); Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The absence of symptoms constitutes negative evidence and opposes the claim. Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002). The Board finds that a psychiatric disorder was not shown in service and no psychosis was shown within one year following the Veteran's separation from service. To the extent that the Veteran claims that he has a psychiatric disability related to service, the Board finds that a psychiatric disorder is not a condition under case law where lay observation has been found to be competent to establish a diagnosis and the determination as to the presence of the disorder therefore is medical in nature, that is, not capable of lay observation. Savage v. Gober, 10 Vet. App. 488 (1997) (on the question of whether the Veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Where the determinative issue involves a question of a medical diagnosis, not capable of lay observation, competent medical evidence is required to substantiate the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or medical opinion. 38 C.F.R. § 3.159 (2012). As a lay person, the Veteran is not qualified or competent, through education, training, or experience to offer a medical diagnosis of a psychiatric disorder. For this reason, the Board finds that the statements of the Veteran that he has a psychiatric disorder related to service are not competent evidence. Under certain circumstances, lay evidence may establish a diagnosis of a simple medical condition. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; 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). Although the Veteran is competent to describe some of his symptoms, the diagnosis of a psychiatric condition and the medical causation are not subject to lay observation. The determination as to the presence, type, and cause of a psychiatric condition is medical in nature and not capable of lay observation. Additionally, by regulation, the diagnosis of PTSD requires medical evidence diagnosing the condition in accordance 38 C.F.R. § 4.125, that is, a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV). 38 C.F.R. § 3.304(f) (2012). For that reason, a psychiatric disorder is not a simple medical condition that a lay person is competent to identify. Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). To the extent that the post-service treatment records contain a diagnosis of PTSD, the clinicians who have diagnosed PTSD have not discussed the criteria for a DSM-IV diagnosis of PTSD and whether such criteria had been met by the Veteran. 38 C.F.R. § 3.304(f) (2012). Additionally, the diagnosis of PTSD recorded in the clinical treatment notes was based on the Veteran's reported military stressors to include combat, and the Veteran did not serve in combat. Thus, the probative value of the medical records that contain a diagnosis of PTSD attributed to combat is greatly diminished because those diagnoses were made based on reports by the Veteran that the Board finds are not credible and were inconsistent with the factual record. Reonal v. Brown, 5 Vet. App. 458 (1993) (medical opinion based upon an inaccurate factual premise has no probative value). Furthermore, no VA psychologist or psychiatrist has diagnosed PTSD based on a fear of hostile military or terrorist activity, and the evidence does not show that the Veteran served in combat. Moreover, the March 2007 examiner stated that Veteran did not have a military experience that would qualify for the Criterion A of PTSD, and that he may have PTSD related to a trauma he suffered as a civilian when he was working as a convenience clerk in a gas station and was shot in the foot; however, the Veteran did not mention the incident or his "PTSD" symptoms until the examiner mentioned it. The January 2013 examiner also stated that there was no persuasive evidence in support of PTSD from service. The Board finds that the preponderance of the competent medical evidence shows that it is not at least as likely as not that the Veteran currently suffers from PTSD that meets the criteria for a DSM-IV diagnosis of PTSD, and in the absence of competent medical evidence linking any current PTSD diagnosis to a stressor during his service, service connection for PTSD must be denied. With regard to service connection for a psychiatric disorder, other than PTSD, post-service medical records document psychiatric treatment for diagnoses variously diagnosed as outlined above. Those disabilities were diagnosed after the Veteran's separation from service. The determinative question in this case involves causation. On the question of medical causation, medical evidence of an association or link between a current psychiatric disorder, first noted after service, and service, there is no competent medical evidence that supports the claims. 38 C.F.R. § 3.303(d) (2012). None of the Veteran's medical providers have related a psychiatric disorder, to include PTSD, to his reported in-service stressors or to any other aspect of his military service. To the extent that the Veteran has been diagnosed with a personality disorder, even assuming that the Veteran did have a pre-existing personality disorder, service connection would still not be warranted absent a showing that a separate psychiatric disability had been incurred in or aggravated by service and superimposed upon that pre-existing personality disorder. 38 C.F.R. §§ 4.9, 4.125(a), 4.127 (2012); Carpenter v. Brown, 8 Vet. App, 240 (1995); Beno, 3 Vet. App. 439. That has not been shown here. There is no competent evidence of record which shows the Veteran suffered a disability which was superimposed upon his personality disorder during service. Therefore service-connection for a personality disorder cannot be granted. The Board may consider only competent, medical evidence to support its findings as to questions involving a medical diagnosis that is not capable of lay observation. The Board may only consider competent medical evidence of medical causation because lay assertion on medical causation is not competent evidence. In the absence of competent medical evidence of a diagnosis of PTSD that meets the DSM-IV requirements and is due to a stressor in service or due to fear of a hostile military or terrorist act, and as the weight of the competent medical evidence is against a finding that any other psychiatric disorder, is causally related to service, the Board finds that the preponderance of the evidence is against the claim that a psychiatric disorder was incurred in or aggravated by service, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, 1 Vet. App. 49. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs