Citation Nr: 1319230 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 09-50 768 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for a psychiatric disorder, to include cognitive disorder, bipolar disorder, mood disorder, obsessive compulsive disorder, and attention deficit disorder with hyperactivity, to include as secondary to a traumatic brain injury (TBI). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1993 to May 1996 and had additional service in the National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. Jurisdiction of the case has since been transferred to the Reno, Nevada RO. The Veteran and his wife testified before a Decision Review Office (DRO) at the RO in Boise, Idaho in April 2010. This transcript has been associated with the file. FINDING OF FACT A psychiatric disorder is not shown to be due to a disease or injury in-service or to any incident of military service. CONCLUSION OF LAW The criteria for the establishment of service connection for a diagnosed psychiatric disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA 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, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The notice requirements were met in this case by a letter sent to the Veteran in August 2008. This letter advised the Veteran of the information necessary to substantiate his claims and of his and VA's respective obligations for obtaining specified types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). This letter also advised the Veteran of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. The Veteran's service treatment records and VA treatment records are in the file. The VA has also obtained private treatment records and records from the Social Security Administration (SSA) and associated them with the file. The Veteran has not indicated that there are any additional outstanding records to be obtained. The duty to assist with obtaining medical records has been satisfied. 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. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The Veteran was afforded a VA medical examination in May 2009 and July 2010 for his claim. These opinions were rendered by medical professionals following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history. The examiners provided a detailed explanation for the conclusions that were reached. Therefore, the Board finds that the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the Veteran in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a 'competent' source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when 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); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. In certain instances, however, lay evidence has been found to be competent with regard to a disease with 'unique and readily identifiable features' that is 'capable of lay observation.' See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Analysis The Veteran contends that he has residuals of a traumatic brain injury, to include a psychiatric disorder, which occurred in service when he fell down the stairs and hit his head. As discussed below, the preponderance of the evidence is against the claim and the appeal will be denied. The Board has reviewed the Veteran's service treatment records and notes that the Veteran was given an examination at entrance to service in September 1992. He reported no trouble sleeping, no depression or excessive worry, no loss of memory, no nervous trouble and no periods of unconsciousness. On examination no psychiatric disorder was found. On November 6, 1994 the Veteran blacked out, fell down the stairs, and sustained a laceration on his head which was not sutured. At the hospital the Veteran reported that he did not know what happened to cause him to fall. He was oriented to time and place, but not person. He was monitored at the hospital and the notes show he was sleeping for a portion of the day, but was easily aroused by voice. He was diagnosed with post concussion syndrome and was discharged the same day. X-rays showed no acute osseous trauma of the skull and a normal cervical spine. The following day the Veteran was seen for follow up and reported a frontal headache. He denied any visual disturbances, numbness, or tingling in his extremities. He was oriented times 3, but was slow in responses. Although the Veteran was seen on numerous occasions following this incident, there is only one reference to memory loss problems or residuals of the fall. On November 17 and November 18, 1994 the Veteran was treated for complaints of flu-like symptoms. In March 1995 the Veteran reported with symptoms of tinea cruris. In August 1995 the Veteran was given an audio examination. In September 1995 the Veteran underwent surgery for a right distal fibular fracture. In November 1995 the Veteran had lung x-rays taken which showed a normal chest. At his November 1995 medical examination the Veteran reported that he experienced memory loss or amnesia and was treated at Weed Hospital. He denied trouble sleeping, depression or excessive worry, nervous trouble or periods of unconsciousness. The examiner found no defects on examination. In January 1996 the Veteran requested a permanent limited duty profile due to his right leg condition. In February 1996 the Veteran complained of low back pain and numbness in his legs. The neurologist noted that the Veteran had previously experienced amnesia and forgetfulness. On examination there were no neurological defects noted. The Veteran was noted to have a somewhat suspicious affect and the examiner found that there was a probably psychogenic component. The Veteran could calculate, spell, and recite presidents, but had amnesia for personal information. In February 1996 the Veteran underwent a CT scan of his head which showed normal results. In April 1996 the Veteran underwent a comprehensive medical evaluation. The review of his test results was negative for evidence of cognitive or memory deficits. The Veteran was considered neuropsychologically fit for full duty. In December 2008 the Veteran was put on a permanent profile due to multiple psychiatric diagnoses which needed to be treated. In April 2009 a statement from the California National Guard noted that the Veteran may be eligible for an administrative discharge due to psychiatric disorders. The Veteran filed a claim of service connection in November 1996, six months after separation from service, for lower back pain and a lower right leg disability. He did not report having a psychiatric disorder on this claim. The Veteran did not file his current claim for a psychiatric disorder until August 2008, almost 12 years after separation from service. This evidence weighs against his claim that he has had a psychiatric disorder since separation from service. The law also provides that even if a chronic condition is not shown during service, service connection may be established under 38 C.F.R. § 3.303(d) if the evidence shows a disease first diagnosed after service was incurred in service. In June 2000 the Veteran reported memory loss for the previous 5 years. In a March 2008 VA treatment record the Veteran reported that his erratic behavior and mood swings began in 1995 or 1996 when he fell down the stairs in service and was found with severe bleeding. He was diagnosed with a mood disorder and the examiner was to rule out bipolar disorder due to a TBI. He was also hospitalized in March 2008 with suicidal ideations. A September 2008 MRI showed that the Veteran had bilateral hippocampal atrophy greater on the right side. The clinical correlation was suggested for the possibility of prior head trauma or hypoxic injury. In October 2008 the Veteran reported memory loss for the previous 5 years, which his wife indicated had worsened recently. The examiner noted the September 2008 MRI findings as well as an October 2008 VA MRI which showed an unremarkable noncontrast brain MRI. However, the examiner interviewed the Veteran and found that the validity of the tests was questionable and the psychiatric evaluation results indicated the Veteran overly endorsed bizarre and unlikely symptoms. As a result, both of these assessments would not be a valid representation of his neuropsychological status. It is significant that the examiner observed that the Veteran's presentation of symptoms was not consistent with known patterns regarding mild traumatic brain injury. In a November 2008 VA treatment record the Veteran referenced feeling depressed and sleepy with decreased memory, all of which he related to the in service incident. A December 2008 statement from a VA psychiatrist noted that the Veteran was treated for multiple psychiatric disorders, to include a mood disorder due to a TBI. In January 2009 the Veteran was diagnosed with severe obsessive compulsive disorder, and a mood disorder and cognitive disorder both due to a TBI. In May 2009 he was diagnosed with bipolar 1 disorder, in partial remission, and cognitive disorder (post concussional). The Veteran began receiving benefits from the SSA in April 2009 due to organic mental disorders and an intracranial injury. The Veteran was afforded two VA examinations in May 2009. The TBI examiner found evidence of depression, obsessive compulsive disorder, and bipolar disorder. The Veteran's reflexes were normal, his nerve test results were normal, and his motor examination was normal. On further examination the neuropsychologist found that the Veteran presented inconsistent answers, his effort was poor, and he scored well below average on portions that even a severely brain injured person would do well on. The examiner questioned any responses made by the Veteran that were in any way subjective. The examiner concluded that the Veteran was trying to exaggerate his degree of cognitive impairment. The examiner also noted that the Veteran had no disability regarding memory when discussing his right ankle symptoms. The examiner noted this was in stark contrast to the claims made during the TBI section. He ultimately opined the Veteran did not have a cognitive defect that was caused by or a result of military service, to include the November 1994 fall. The examiner explained that the Veteran had a normal neurological evaluation in 1996 and a normal neuropsychiatric evaluation in 1996. He concluded the findings were inconsistent with any pattern attributed to TBI as TBI symptoms do not get worse after the first 6 months and there would be no reason to expect findings present to be due to the TBI. The Veteran more likely had psychological issues that were not related to his military head injury. Another examining neuropsychologist noted he had reviewed the Veteran's service treatment records, to include the November 1994 records related to his fall and the Veteran reported memory problems, in that basically he could not remember anything. The examiner observed that the Veteran's demeanor suggested a naïve attempt to highlight the impression of cognitive impairment in that he had good memory for his medical history as far as seeking disability, but he had difficulty providing personal information. The examiner noted that the Veteran's performance on measures of effort and motivation was questionable. He scored very poorly on a test that is known to be objectively very easy and his scores were well below those of acute, severely brain injured persons. He also demonstrated unusual variability in response latencies with testing, and the examiner was not clear what this was due to. Accordingly, test results were to be interpreted with causation. The examiner noted a normal neuropsychological test 2 years after the accident, but that the Veteran's wife's notes stated a dramatic change in functioning beginning in 2000. Significantly as it bears upon the Veteran's credibility, these reports were inconsistent with cognitive and/or emotional sequelae associated with brain injury. The examiner observed that it was unlikely that the Veteran's demonstrated cognitive and emotional changes were directly associated with the Veteran's history of concussion/mild TBI in 1994. In a December 2009 VA psychology consultation the Veteran reported almost no memory for basic historical events in his life as well as depression. He related this to the in service accident. However, and similar to previous test, the examiner interpreted test results as indicating the Veteran's attempt to portray himself in a negative manner and that he likely exaggerated psychological complaints and problems. Thus, personality assessment inventory results were invalid. Motivation testing was within normal limits. On behavioral observations the Veteran also exaggerated movement. He also attempted to use a technique for answering questions which would have required significant memory and provided the wrong response, when in fact he was answering correctly. His reported memory complaints were inconsistent with behavior observed during the testing and outside the testing situation. His memory complaints were not consistent with memory disorders. He was diagnosed with factitious disorder and noted to not have a psychotic disorder. The examiner did note that the presence of factitious symptoms did not preclude the coexistence of true psychological symptoms, but due to the Veteran's testing approach it was difficult, if not impossible to assess his actual level of psychiatric distress. In a February 2010 VA psychiatry initial evaluation the physician interviewed the Veteran and, again significantly found that his presentation of symptoms was more consistent with voluntary production of symptoms for primary and secondary gains, to include disability allowance, and to be taken care of by his wife. He could not find a good explanation for symptoms such as anxiety and depression and he was not convinced the Veteran had bipolar disorder. His opinion was that the findings more clearly showed factitious disorder. In an April 2010 VA treatment record the examiner opined the Veteran's symptoms, history, and neuropsychiatric testing was more consistent with factitious disorder than any of his other previous diagnoses. His rationale was that the Veteran had a number of reasons for assuming the "sick role," including the ability to be free from responsibility, the desire to be comforted and cared for by his wife, and other external incentives including applying for disability payments. The examiner also stated the Veteran may have other comorbid psychiatric diagnoses. The Veteran was also afforded a VA examination in July 2010. Again he reported depression, anger/frustration, decreased interest and motivation, and memory loss. The examiner noted that the Veteran had many different psychiatric disorder diagnoses that the Veteran was claiming these were related to the November 1994 incident. Treatment reports have indicated a mild heady injury, although the Veteran described it as more severe. He opined it was less likely than not that the Veteran's mood problems were related to the 1994 injury. In October 2010 a VA psychiatrist stated that the previous diagnoses were incorrect for factitious disorder and malingering. The examiner stated that the clinical picture was consistent with brain damage. To the extent that the Veteran's representative argues the complete personnel file is not in the claims file, the Board observes that there are multiple counseling reports from service showing that the Veteran experienced personality conflicts with his superiors following the November1994 incident. The Veteran suffered a head injury in service. The Veteran, his spouse, friends, and family have also offered statements and testimony to the changes they noticed in him following separation from service. There is no evidence that any additional, outstanding personnel records should be obtained or that they would provide supplemental information not already available. In addition to the evidence that the Veteran filed a claim for service connection in 1996 and failed to reference a psychiatric disorder, the evidence includes statements from the Veteran, his wife, friends, and family asserting that his psychiatric problems began following the November 1994 incident. These statements are competent , but the Board must then determine their credibility. The reported history of a continued psychiatric disorder since active service, while competent, is not credible. The Veteran filed a claim for compensation in November 1996, 6 months after separation from service, and did not report a psychiatric disorder, although the Veteran later complained that his symptoms had existed since service. The Board cannot determine that the lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. However, the Veteran's service treatment records and November 2006 claim weigh against the Veteran's contentions that his psychiatric disorder is related to, and has been present since service. The Veteran has a long and demonstrated history of symptom exaggeration in an apparent attempt to gain compensation. The October 2008 psychologist found that the validity of the tests was questionable and the psychiatric evaluation results indicated the Veteran overly endorsed bizarre and unlikely symptoms. The Veteran's presentation of symptoms was not consistent with known patterns regarding mild traumatic brain injury. Both May 2009 VA examiners, one of whom is a neuropsychologist, found that the Veteran was inconsistent with his answers and that his responses were exaggerated. The May 11 examiner also noticed a stark difference in the Veteran's ability to recall events related to his ankle injury versus general memories. Both examiners found that his diagnoses were not related to service and his symptoms were inconsistent with TBI residuals. In December 2009 a VA Ph.D. examiner found that the Veteran's memory complaints were inconsistent with behavior observed during the testing and outside the testing situation. His memory complaints were not consistent with memory disorders. Following this in February 2010, and April 2010, a VA physician found that the Veteran's symptoms were more consistent with factitious disorder than any other diagnosis. The July 2010 VA examiner also found that it was less likely than not that the Veteran's diagnoses were related to service. These reports consistently show that the Veteran had poor effort on examination and provided inconsistent, at times exaggerated, responses to testing. The Board has weighed the findings of the examiners against the Veteran's statements that his memory loss is related to service. However, the Board assigns the medical opinions more probative value. This is due to numerous examiners finding that the Veteran's symptoms did not match known memory or TBI residuals or disorders and the consistent explanations provided for why the Veteran was not believed to have TBI residuals. Accordingly, the Board finds the Veteran's statements lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. The weight of the competent evidence does not attribute any psychiatric disorder to active duty. The examiners failed to provide a nexus between service, to include the November 1994 incident, and the Veteran's current psychiatric diagnoses. The examiners offered explanations to show that the Veteran's symptoms did not correlate with known memory or TBI disorders and that his symptoms were inconsistent in what he could remember and what he could not recall. Accordingly, the medical evidence of record is assigned a greater probative value than the Veteran's statements. The Board is aware that in October 2010 a VA psychiatrist stated that the previous diagnoses of factitious disorder and malingering were not correct. The examiner stated that the clinical picture was consistent with brain damage. The examiner's assessment is not probative. The Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). The October 2010 psychiatrist offered no rationale for the opinion that the Veteran's psychiatric diagnoses were due to brain trauma. The examiner did not state what evidence showed the Veteran's diagnoses were related to brain trauma, nor did the opinion acknowledge the trauma suffered in service and how it would cause the current diagnoses. In contrast, numerous VA examiners have provided thorough examinations and interviews of the Veteran, to include reviewing the medical records from service, as well as post service, in coming to conclusions that any current diagnosis is not related to service. See e.g., May 2009 VA examination report, April 2010 VA psychiatry evaluation, and December 2009 psychiatry consultation. The Board assigns greater probative value to the medical examiners' opinions with explanations and those showing a thorough review of the claims file. The October 2010 opinion is offered little probative value. The Board has considered the statements and testimony of the Veteran, his wife, friends, and family state that his memory problems began after the in service fall. An October 2004 buddy statement noted that the Veteran had selfless service, unit loyalty, and friendship while serving on active duty. A November 2008 statement from the Veteran's co-workers stated that he has memory loss. A statement from another co-worker who worked with the Veteran in the late 1990s to early 2000s referenced the Veteran's leg injury and the problems it caused him when working on computers. The co-worker did not reference any memory loss or psychiatric disorders. The Veteran's mother also submitted a statement attesting to the Veteran's memory loss. The Veteran's wife has also submitted statements and testimony regarding the Veteran's condition. She indicated that his psychiatric disorder cause symptoms including memory loss, impulsive purchases, the inability to hold a job, problems with focusing, suicidal tendencies, and inappropriate relationships. Although lay persons such as the Veteran are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the issue of diagnosing a psychiatric disorder as secondary to a TBI or service, this falls outside the realm of common knowledge of a lay person. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the Veteran has offered only conclusory statements regarding the relationship between his in service incident and current psychiatric diagnoses. The VA examiners have reviewed service and post-service treatment records, considered his reported history, and examined the Veteran. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for a psychiatric disorder and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). ORDER Entitlement to service connection for a psychiatric disorder is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs