Citation Nr: 1319763 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 11-01 296 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: J. Michael Woods, Attorney-at-Law ATTORNEY FOR THE BOARD L. Zobrist, Associate Counsel INTRODUCTION The Veteran served on active duty with the U. S. Navy from September 1988 to October 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in August 2010, a statement of the case was issued in January 2011, and a substantive appeal was received that same month. After additional development, a supplemental statement of the case was issued in March 2012. The Board notes that the Veteran has submitted additional pertinent evidence to the Board and has waived his right to have the RO consider it in the first instance. 38 C.F.R. § 20.1304(c). In keeping with the judicial holding in Clemons v. Shinseki, 23 Vet.App. 1 (2009), the following decision contemplates the question of whether any chronic psychiatric disorder (however diagnosed) is causally related to the Veteran's service . FINDING OF FACT A chronic acquired psychiatric disability was not manifested during the Veteran's active duty service, or within one year of discharge, nor is any current chronic acquired psychiatric disability causally related to such service. CONCLUSION OF LAW An acquired psychiatric disability was not incurred in or aggravated during the Veteran's active duty service. 38 U.S.C.A. § 1131, 5107 (West 2002); 38 C.F.R. § 3.303, 3.304, 4.125 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant with proper notice by letter dated in February 2010. This notice complied with the specificity requirements of Dingess, identifying the five elements of a service connection claim, and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. By letter in January 2011, the RO acknowledged the Veteran's contentions regarding personal trauma during service and furnished a questionnaire with appropriate notice in compliance with 38 C.F.R. § 3.304(f)(5) (2012). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. VA has obtained service treatment records (STRs), private treatment records identified by the Veteran and for which he signed release waivers, and Social Security Administration records. The Veteran was afforded VA examinations in April 2010 and January 2012. In addition, the Veteran indicated, on his January 2011 VCAA Notice Response, that he did not have additional evidence to provide to VA, and his representative stated in an October 2012 letter that all the evidence that the Veteran wished the Board to consider had been submitted. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations/opinions obtained in this case are adequate, as the opinions are predicated on examinations of the Veteran and review of his claims file, to include his STRs and postservice medical records identified by the Veteran. They consider the pertinent evidence of record, to include statements of the Veteran regarding his symptoms. Rationales were provided for the opinions proffered. The Board also notes that the record as a whole, as discussed below, supports the examiners' opinions. The Board notes that the Veteran has indicated on two occasions (letters dated in January 2011 and April 2012) that he has additional evidence in support of his claim, but stated affirmatively both times that he will not provide such evidence to VA. VA also requested several times that the Veteran provide a release waiver to allow VA to acquire private treatment records from Dr. K. J.; the Veteran declined to provide such waivers. He also indicated twice (January 2011 VCAA Notice Response and October 2012 letter) that he had no additional information to provide. The Board notes that the duty to assist is not a one-way street. "If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As the Veteran has clearly indicated that he has no further evidence that he is willing to provide to VA, the Board finds that no additional assistance in this regard is required and that remand for further development would serve no useful purpose. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). Analysis The Board further notes that it has reviewed all of the evidence in the Veteran's claims file and in "Virtual VA" (VA's electronic data storage system), with an emphasis on the evidence relevant to the matter on appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury or disease in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. 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 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). Personality disorders are not diseases or injuries within the meaning of applicable legislation regarding VA compensation benefits. 38 C.F.R. § 3.303(c). Certain chronic disabilities, such as psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1133; 38 C.F.R. §§ 3.307, 3.309. The term "psychosis" means any of the following disorders listed in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, of the American Psychiatric Association (DSM-IV-TR): (a) Brief Psychotic Disorder; (b) Delusional Disorder; (c) Psychotic Disorder Due to General Medical Condition; (d) Psychotic Disorder Not Otherwise Specified; (e) Schizoaffective Disorder; (f) Schizophrenia; (g) Schizophreniform Disorder; (h) Shared Psychotic Disorder; and (i) Substance-Induced Psychotic Disorder. 38 C.F.R. § 3.384. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, supra. A veteran is competent to describe symptoms that he experienced in service, or at any time after service, when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (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, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303, 308 (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). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. at 310 ("[T]he Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms."). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, a veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition; he is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). In his initial claim for entitlement to service connection for an acquired psychiatric disorder, received in February 2010, the Veteran stated that his disability began the day he enlisted in September 1998 and was the result of physical and verbal assaults from his company commander. The Veteran is competent to describe a physical assault that he experienced and to state that his observable symptoms began while in service. However, as discussed below, the Board finds that the Veteran's assertions regarding the asserted in-service physical assault and the onset of his current acquired psychiatric disability are not credible, and the evidence does not otherwise support any such contentions. Service Treatment Records On his September 1988 enlistment medical history report, the Veteran noted that he wore glasses and was previously hospitalized for a broken jaw. He also noted that he had never attempted suicide and had never experienced frequent trouble sleeping, depression or excessive worry, or nervous trouble of any sort. On the accompanying enlistment examination, the examiner evaluated the Veteran's neurologic and psychiatric state as clinically normal. On a Dental Health Questionnaire, completed the next month, the Veteran stated that he had been hospitalized in 1986 for a hip infection and that he had experienced, or was experiencing, nervousness and hives. The examiner found that the Veteran had hives from anxiety and a history of a broken jaw. The Veteran's personnel records show that, less than one week later, the Veteran wrote a letter to his then-fiancée, stating that he was going to kill himself; there was no mention of physical assault. The record reflects that the fiancée subsequently called the Veteran's mother, who called the company commander. The record reflects that, on October 22, 1988, after the company commander was informed of the Veteran's suicidal expression, the Veteran stated that he wanted out of boot camp at any cost, even death, and that, if the stress of boot camp was too great, he would hang himself. The Veteran also reported to his commander that "he has told his mother that he would kill himself on several occasions when things didn't go his way." The Veteran was then escorted to the mental health clinic. The mental health evaluation recorded the Veteran's complaints that he had difficulty adjusting to the stress of boot camp; he did not, at any time, allege that he was the victim of assault or other trauma while in service. The Veteran also reported that, for the last year, he had experienced suicidal ideation "when things didn't go his way." He reported a prior suicide attempt in school. The clinician noted the Veteran's depressed mood and stated that the Veteran's thoughts "center[] around his inability to tolerate stress of training and drive to return home." The Veteran was diagnosed with adjustment disorder with depressed mood and dependent personality traits, and the clinician recommended immediate discharge from active service ("walked through") due to nonadaptability. The Veteran was administratively discharged from active service on October 25, 1988, with an entry level separation by reason of performance/conduct. The Veteran's personnel records confirm that the Veteran expressed suicidal ideation while in service, but such records, and the Veteran's service treatment records, note conflicting statements over a very short period of time. The Veteran first indicated, upon entry to service, that he had never had suicidal ideation and had never been treated for a mental health condition. Then, when he wanted to leave service, he stated that he had experienced suicidal ideation for the past year and had, prior to service, received mental health treatment after he made a suicidal gesture by cutting himself with a knife. Given the Veteran's inconsistent statements from enlistment through discharge, the Board finds that the Veteran is less than credible with respect to the onset of his psychiatric disability. Nonetheless, the Veteran is presumed to have entered service in sound condition. Furthermore, the Board notes that the Veteran's personnel records reflect his October 22, 1998, statement that he tells his mother that he is suicidal for the purpose of getting what he wants, although his October 24, 1998, service treatment records reflect that he actually feels suicidal when he does not get his way. He also stated that he had difficulty adjusting to the stress of boot camp and "want[ed] out of boot camp at any cost." The Board finds that the Veteran's statements indicate a self-serving intent to act in a manner that would result in his separation from service and that, therefore, the Veteran's statements regarding the nature of his in-service psychiatric condition are not credible. Additionally, the Veteran received a mental health examination on October 24, 1988, less than five weeks after his entrance examination. The Veteran's mental health examination and his other service treatment records are negative for any physical findings, such as bruising, that would indicate that the Veteran was involved in a physical assault. The Board finds it reasonable that, if the Veteran had received wounds or other injuries as a result of physical assault, the mental health examiner would have noted such during the examination; the examiner did not. Finally, to the extent that the Veteran's personnel record reflects "hits" for infractions, the Board finds that the term refers, colloquially, to the assignment of demerits and not to a physical blow. Postservice Medical Records Although the Veteran asserted, in his initial claim, that he began receiving treatment for a psychiatric disability in November 1990, the earliest postservice medical records in the record relate to a July 1997 on-the-job orthopedic injury, at which point the Veteran indicated that he had never been told that he had a chronic or serious illness, had never been in military service, and had never suffered from a nervous disorder or "other diseases". An October 1997 record reflects that the Veteran sought treatment for a head injury, at which time the Veteran indicated that he was under stress because he had been fired and did not indicate that his stress was related to service. Private treatment records from 1998, approximately 10 years after separation from service, are the first to show treatment for an acquired psychiatric disorder, variously diagnosed as major depressive disorder, panic disorder, adjustment disorder, dissociative identity disorder, PTSD, and personality disorder not otherwise specified. The earliest treatment record mentioning a psychiatric disability is in August 1998, from Range Medical Service, at which time the Veteran said that he had been experiencing symptoms of impulsiveness, violence, getting mad, and irritation at minor inconveniences, for two years, or six years following his separation from service; that record does not ascribe those symptoms to any particular origin and is, thus, less probative as to any nexus between the Veteran's current disability and his active service. September 1998 treatment records are the first to document any assertions by the Veteran that his psychiatric disability was related to his service. On a detailed initial evaluation conducted that month, Mr. G. M., a licensed clinical social worker, noted briefly the Veteran's contention that he was "discharged from the military in 1989 because of suicidal thoughts because he thought people were coming after him"; the Veteran did not assert that he was the victim of assault or any other trauma while in service. The social worker listed the Veteran's Axis IV (psychosocial and environmental) diagnoses as violence between his father and stepfather, the murder of his father, his inability to remain employed, conflict with his wife's family, financial concerns, two prior bankruptcies, and childhood sexual abuse by a family member. The examiner did not note military service or an incident of service under the Axis IV diagnose. Mr. G. M. also recorded that the Veteran had a history of suicidal thinking but had never made a suicide attempt and had no prior history of mental health problems. Mr. G. M. diagnosed the Veteran with major depression, recurrent, severe, with psychotic features, panic disorder with and without agoraphobia, and rule out PTSD. (See also October 1998 letter providing Axis I diagnoses and noting the Veteran's inability to work passed on those diagnoses.) He was also diagnosed with personality disorder, not otherwise specified, with dependent and avoidant features. The Board finds that, if the social worker believed that the Veteran's military service contributed to his then-current psychiatric disorders, such influence would have been one of the many psychosocial and environmental factors cited under the Axis IV diagnoses; it was not. Additionally, the Board finds that, if the Veteran's in-service suicidal ideation was related to physical assault, it would have been reasonable for the Veteran to have mentioned such when discussing the issues causing him psychiatric distress; he did not. The Veteran was referred that same day to Dr. K. C. for further evaluation. Dr. K. C. recorded the Veteran's statement that he had felt suicidal while in the military and that he "has been depressed and it's been worse in the last five years." She recorded the Veteran's symptoms of decreased sleep, panic, anxiety, decreased interest and energy, suicidal ideation, and "never [feeling] really good mood-wise" and diagnosed the Veteran with major depression, recurrent, with psychotic symptoms and panic disorder with agoraphobia. Dr. K. C. did not provide a rationale for her opinion, nor did she attribute the Veteran's psychiatric disability to his military service. Thus, the Board finds this examination less probative as to any nexus between the Veteran's current disability and his military service. Moreover, the Board notes the significant difference between the Veteran's description of his symptom history (two years) in the morning, to Mr. G. M., and in the afternoon (at least five years), to Dr. K. C. The Board finds that this significant discrepancy in reporting renders the Veteran's statements, that day, regarding his symptom history, less than credible. Additional September 1988 treatment notes from Range Medical History record the Veteran's symptoms of anxiety, nervousness, sweating, nausea, and the inability to handle crowds and provide a diagnosis of depression. The source of this anxiety was described as the Veteran's inability to keep a job, and the examiner stated that "stress at work is making [the Veteran] decompress." October and November 1998 treatment notes from the same facility note the existence of current psychiatric symptoms and treatment but do not discuss any further potential contributors to the Veteran's acquired psychiatric disability. The Board finds that, if the Range Medical Services clinical examiners believed that the Veteran's military service contributed to his then-current psychiatric disorders, such influence would have been noted; it was not. Additionally, the Board finds that, if the Veteran's in-service suicidal ideation was related to physical assault, it would have been reasonable for the Veteran to have mentioned such when discussing the issues causing him psychiatric distress; he did not. Dr. K. J. provided a letter supporting the award of Social Security Administration disability benefits, dated in October 1988, and averring that the Veteran's psychiatric symptoms were "a significant disability" that would make it "very difficult for [the Veteran] to maintain gainful employment." However, that opinion addresses only the severity of the condition at that point in time and does not provide a nexus between the current disability and the Veteran's military service. Furthermore, it is not clear where Dr. K. J. obtained this history. From the context of the letter, it is clear that Dr. K. J. was providing an "initial evaluation" of the Veteran and had not been a long-term treatment provider such that he would have personal knowledge of the Veteran's "long history of psychiatric disorders." Dr. K. J. did not indicate that he had read the Veteran's claims file or reviewed other medical records. As there is no nexus opinion and no credible evidence to support Dr. K. J.'s conclusion regarding the duration of the Veteran's symptoms, the Board finds this opinion to be less probative. A medical opinion is inadequate if it is not based on consideration of prior medical history and examinations. Moreover, a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed evaluation of whether direct service connection is warranted. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). The probative value of medical opinions is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guarneri v. Brown, 4 Vet. App. 467, 470-71 (1993). There is no requirement that additional evidentiary weight be given to the opinion of a medical provider who treats a veteran; courts have repeatedly declined to adopt the "treating physician rule." See White v. Principe, 243 F.3d 1378, 1381 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). The Veteran applied for Social Security Administration disability benefits in November 1998. He stated that his symptoms began three years prior and that he does not handle authority well because he feels like his supervisor is going to hurt him. The Board notes again that there is a discrepancy between the symptom history described in November 1998 (three years) and that described in September 1998 (two years and at least five years) and again finds the Veteran's statements as to onset of psychiatric symptoms less than credible. Furthermore, the Board finds that, if it was a contributing factor to his then-current symptoms, it would have been reasonable for the Veteran to mention his military service when applying for Social Security Administration disability compensation; he did not. On December 1998 examination by Dr. J. H., the Veteran reported that he had served 60 days with the Army (the Veteran served in the Navy) but was discharged for auditory hallucinations, a voice the Veteran calls "[redacted]." Dr. J. H. noted a family history of panic attacks, anxiety, and auditory hallucinations, as well as the Veteran's report of intrusive thoughts, flashbacks, and nightmares related to his childhood sexual assault and his father's murder. Diagnoses provided were PTSD, chronic; major depressive disorder, severe, with psychotic features; panic attacks with agoraphobia; dissociative disorder not otherwise specified; and mild mental retardation. Axis IV diagnoses included frequent job loss due to his disability, two bankruptcies, and special education classes during school; military service was not listed. Again, the Board finds that, if Dr. J. H. believed that the Veteran's military service contributed to his then-current psychiatric disorders, such influence would have been one of the many outside stressors cited under the Axis IV diagnosis; it was not. Additionally, the Board finds that, if the Veteran's in-service suicidal ideation was related to physical assault, it would have been reasonable for the Veteran to have mentioned such when discussing the issues causing him psychiatric distress; he did not. Furthermore, the Board notes that the Veteran's statement that he was discharged for auditory hallucinations is inconsistent with the service treatment and personnel records discussed above. Consequently, the Board finds that the Veteran's statement regarding the onset of his auditory hallucinations is less than credible. An undated treatment record notes diagnoses of panic, anxiety, and depression. However, no nexus opinion was provided. That the Veteran has been experiencing psychiatric symptoms since 1998 is not in dispute, and the record does not indicate that it was completed prior to 1998. Likewise, a December 1998 Social Security Administration evaluation form, completed by Dr. R. L., describes the Veteran's current symptoms, but provides no nexus opinion. Thus, the Board finds that these records are not probative evidence supporting a nexus between the Veteran's current disability and his military service. In January 2000, the Veteran was hospitalized for an intentional overdose of Prozac and Xanax. He was diagnosed with a single episode of major depression. Stressors reported over the course of his hospitalization included an argument with a friend over a credit card, childhood sexual abuse, and his father's death. Again, the Board finds that, if the clinicians treating the Veteran during his hospitalization believed that the Veteran's military service contributed to his then-current psychiatric disorders, such influence would have been one of the many psychosocial and environmental factors cited under his Axis IV diagnoses; it was not. Additionally, the Board finds that, if the Veteran's in-service suicidal ideation was related to physical assault, it would have been reasonable for the Veteran to have mentioned such when discussing the stressors which led to his overdose; he did not. The Veteran received additional treatment in February and March 2000 and February, April, and June 2001 from Dr. K. C. and Mr. G. M; some records are unsigned and the identity of the examiner is unknown. Current symptoms and treatment were noted, but, other than discussion of the Veteran's current legal difficulties, no nexus opinions were provided. Consequently, the Board finds that these records are of little probative value. In March and May 2001, the Veteran was referred, by his attorney and in connection with legal matters, to a licensed psychologist, Mr. S. T. The psychologist described the Veteran's current legal difficulties, examined the Veteran, and administered the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Mr. S. T. noted that a previous MMPI-2 administration had been invalid and that the current administration was borderline valid. The psychologist explained that borderline validity could mean either that the individual was "psychotic or in a considerable amount of psychological turmoil," consistent with incarceration or treatment in a psychiatric facility, or that the individual was "exaggerating and presenting a lot of symptomatology." Symptoms noted include low self-esteem, depression, anxiety, psychotic through process, auditory hallucinations, loss of time, regular panic attacks, and possible suicidal thinking. These symptoms were attributed to the Veteran's legal challenges, marital problems, childhood physical and sexual abuse, and a more recent alleged sexual assault. The Board notes that a page appears to be missing from the March 2001 record. However, the Board finds that this missing page is not necessary to adjudicate the Veteran's claim. The two pages of the report that are in the record reflect the Veteran's statement, recorded in the History of Presenting Complaint (which is present in full) that his depression started after the death of his father. The Criteria for Discharge (also presented in full) identified childhood sexual abuse as the issue that required further concern and is negative for issues related to service. The Board finds that, if Mr. S. T. believed that the Veteran's military service contributed to his then-current psychiatric disorders, that issue would have been listed along with sexual abuse as a concern to be addressed prior to discharge; it was not. In addition, the subsequent May 2001 report by the same examiner is negative for any in-service physical assault. Moreover, the 2001 records are more than 12 years after separation from service; therefore, they do not support a finding of psychiatric symptoms within one year of separation. In October 2001, the Veteran received treatment for a neck injury. The examination report associated with this injury notes "a past history of anxiety and depression," as well as a psychiatric hospitalization three years prior. However, no nexus was discussed. Thus, the Board finds that this examination report is not probative evidence with respect to a possible nexus between the Veteran's current disability and his military service. The Veteran received a Social Security Administration examination in September 2002. The examiner, Mr. R. S., a licensed psychologist, noted the Veteran's assertion that the Veteran was discharged from service for suicidal thoughts after threatening to jump off a building. The Veteran stated that he only threatened to kill himself at that time and that he did not make an attempt until his intentional overdose. The Veteran reported mental health treatment beginning in 1998 but no earlier, and he stated that "[redacted]" did not appear until 1995. The Veteran stated that he "is a rug for people," is taken advantage of, and had not been in any kind of fight since he was 15. Mr. R. S. recorded the Veteran's stated stressors, including childhood sexual abuse, sexual assault in adulthood, legal problems regarding credit card fraud; military service was not mentioned as a current stressor. Mr. R. S. diagnosed a single episode of major depressive disorder, panic disorder with agoraphobia, and personality disorder not otherwise specified. The Board notes that the Veteran's statements on September 2002 examination differ significantly from earlier assertions. He stated that "[redacted]" appeared in 1995, well after service, not in service (and the reason for his discharge) as he stated in December 1998. He also stated that he was discharged after threatening to jump off a roof, rather than after threatening to hang himself, which was his asserted plan in October 1988. Based on these inconsistent statements, the Board finds that the Veteran's lay statements, as recorded on his September 2002 examination, are less than credible. Additionally, the Board notes that the Veteran did not describe any psychiatric treatment between his discharge from service and 1998, the date of the earliest psychiatric treatment records in the record. Once again, the Board finds that, if the Veteran's in-service suicidal ideation was related to physical assault, it would have been reasonable for the Veteran to have mentioned such when discussing the issues causing him psychiatric distress, and to have described all treatment received since his military service, when undergoing a mental health evaluation to determine whether Social Security Administration disability benefits were appropriate; he did not. Additional records associated with the Veteran's application for and request to continue Social Security Administration disability benefits, including those completed by his wife, reflect assertions that the Veteran's condition began no earlier than 1998 and do not discuss his military service. As discussed above, the Board finds it reasonable that, when seeking disability compensation, the Veteran, and his wife, would have reported symptom onset in service, due to an assault, and continuation of symptoms from that time, if such history were accurate; they did not. An additional Social Security Administration evaluation form, completed in January 2003 by Dr. G. K., notes the Veteran's on-going symptoms, but does not mention his military service or discuss the origin of such symptoms. Thus, the Board finds that this evidence is not probative with respect to determining whether the Veteran's current disability is related to his military service. Treatment records from a May 2005 hospitalization following another suicide attempt reflect serious financial and legal stressors and a diagnosis of major depressive disorder, recurrent. The Veteran discussed a history of childhood sexual abuse and his father's murder, as well as the prior suicide attempt by overdose. These psychosocial and environmental factors are consistent with those reported by the Veteran in September 1998 and repeated throughout the 1998-2005 treatment period; thus, the Board finds that the Veteran's statements regarding those stressors are credible. However, the Board finds again that, if the Veteran's in-service suicidal ideation was related to physical assault, it would have been reasonable for the Veteran to have mentioned such at some point between 1998 and 2005, particularly when being treated on an in-patient basis for a suicide attempt; he did not. The first time that the Veteran asserted that he was the victim of physical assault from his company commander, or any other servicemember, while in the military was in his February 2010 claim for service-connected disability benefits, submitted more than 21 years after separation from service and after more than eleven years of psychiatric treatment. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). Following receipt of his claim, VA arranged for the Veteran to receive a medical examination, which was conducted in April 2010. The VA examiner noted that the Veteran's statement, on examination, that he had never had mental health treatment prior to service were inconsistent with his October 1988 service treatment records. The examiner also noted the Veteran's statement that he had first received mental health treatment in 1996, although the record indicates that this treatment began in 1998. Furthermore, the examiner noted that the Veteran's father had died when he was a child, but did not mention the manner of death. Neither the Veteran's previously asserted childhood sexual abuse or his prior legal troubles were mentioned. The VA examiner described the Veteran's current symptoms, discussed the Veteran's assertion that he tried to commit suicide after several physical assaults from his Chief Petty Officer, and conducted a psychiatric examination. The April 2010 VA examiner diagnosed the Veteran major depressive disorder, recurrent, moderate to severe, and personality disorder, with negativistic and narcissistic features. He opined that it was less likely than not that the Veteran's psychiatric disability was caused by, or the result of, his military service because there was no mention of assault or other trauma in the Veteran's records, there was no record of mistreatment by his Chief Petty Officer, and the Veteran's in-service diagnosis was adjustment disorder, which "is not a chronic condition" and would not persist for 20 years after service. As noted above the Veteran's service treatment records from October 1988 are negative for any physical signs of assault, and the Board found that the Veteran's testimony regarding the alleged assault was not credible. The examiner also noted that there was no record of any other mental health treatment until several years after service. The examiner reviewed the Veteran's claims file, considered the Veteran's current symptoms and reported history of treatment (which is roughly consistent with the record and, thus, credible), and provided a reasoned opinion determining that the Veteran's current disability was less likely than not related to service. Thus, the Board finds that this examination is probative and constitutes competent, credible evidence against finding a nexus between the Veteran's current disability and his military service. The Veteran received a private diagnostic assessment from Range Mental Health Center, Inc., from Mr. J. M., a psychological intern, under the supervision of Dr. M. M., a licensed psychologist, in September 2010. The private examiners noted the Veteran's report that he had no symptoms prior to service, that his symptoms have been present since his mistreatment in service, that "he has flashbacks of the abuse," and that his employment difficulties are the result of the asserted in-service personal assault. Although the Veteran mentioned sexual abuse by his uncle, marital trouble, and his father's murder, he nonetheless attributed "all of his mental health symptoms to his treatment during basic training in the Navy." The examiners diagnosed PTSD and major depressive disorder, recurrent, severe without psychotic features. However, the examiners did not discuss PTSD in relation to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. §§ 3.304(f), 4.125. Furthermore, the examiners opined that the Veteran's current disability might be related to service if the Veteran's allegations of in-service assaults were credible. However, as discussed above and below, the Board finds that the Veteran's statements that he suffered an in-service assault are not credible, and thus this opinion is based on an inaccurate factual predicate. See Reonal v. Brown, 5 Vet.App. 458, 461 (1993). Consequently, the Board finds that this opinion is less probative. The Veteran received on-going outpatient mental health treatment from Mr. J. M. and Dr. M. M. from October 2010 to June 2011. During that time, although the Veteran regularly discussed psychological issues related to his father's suicide, he consistently stated that his on-going symptoms, including flashbacks, marital discord, feelings of worthlessness, financial troubles, and gambling are due to his alleged in-service personal assault. For the reasons stated above, the Board finds that the Veteran's statements are less than credible and that the medical opinions recorded in the treatment record are less probative. The Veteran received another VA mental health examination in January 2012. The examiner reviewed the Veteran's claims file and other medical records, noted his prior mental health diagnoses, and recorded the Veteran's statements regarding the alleged in-service physical assault and that, as a result, the Veteran wrote to his mother to tell her that he was going to jump off the barracks roof. (The Board notes that the Veteran's statements on January 2012 examination are not consistent with his October 1988 statements that he wrote to his then-fiancée and that his plan was to hang himself.) The January 2012 VA examiner administered the MMPI-2 and found the results to be invalid. Specifically, the examiner opined that the Veteran "endorsed more deviant items than even seriously disturbed psychiatric inpatients." Thus, the examiner concluded that the Veteran's responses were "noncredible." The examiner also assessed the Veteran's reported symptoms in accordance with the DSM-IV. The examiner stated that, based on those reported symptoms, the Veteran met the diagnostic criteria for PTSD. However, the examiner also determined that, based on the Veteran's noncredible self-reporting on the MMPI-2, the Veteran's history of providing invalid responses on diagnostic evaluation, and inconsistencies in his self-reported psychiatric history, the Veteran's self-reporting with respect to PTSD must also be considered noncredible. Consequently, the examiner opined that the Veteran did not have any mental disorder that conforms to the DSM-IV criteria and that "a determination about any psychiatric diagnosis cannot be made without resort to mere speculation." The January 2012 examiner reviewed the Veteran's claims file and private medical records, considered the Veteran's self-reported current symptoms, and provided a reasoned opinion determining that the Veteran's self-report was invalid and that, therefore, she could not provide a diagnosis without resort to speculation. The examiner was clear that her opinion was based on the Veteran's invalid, noncredible test results, both historically and upon January 2012 examination. As the Board has likewise determined that the Veteran's lay evidence regarding an in-service origin for his current psychiatric disability is less than credible, remand for clarification or a second opinion would serve no useful purpose. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Therefore, the Board finds that this examination is probative and constitutes competent, credible evidence that does not support a finding of a nexus between the Veteran's current disability and his military service. The Veteran's representative arranged for the Veteran to receive a private medical opinion in September 2012 from Dr. A. F. Dr. A. F. diagnosed the Veteran with major depressive disorder, recurrent, severe, with psychotic symptoms, and posttraumatic traits. Dr. A. F. does not dispute the Veteran's in-service diagnosis of adjustment disorder and concurred with the April 2010 VA examiner that adjustment disorder is a temporary condition that does not last 20 years. Dr. A. F. also concurred that the Veteran had not been involved in mental health service until several years following service. Dr. A. F. opined that the in-service adjustment disorder "evolved into" the Veteran's current psychiatric disability, which is, therefore, more likely than not related to the Veteran's military service. However, the private examiner did not discuss how a temporary condition present in October 1998 would "evolve" into a chronic condition years later. An examination that lacks a rationale is not adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, Dr. A. F. did not discuss the other stressors associated with the Veteran's mental health treatment from 1998-2005. An opinion that is not based upon consideration of the Veteran's prior medical history is likewise inadequate. Id. Finally, the private examiner based his conclusion on lay evidence provided by the Veteran, his wife, his mother, and his former employer. For the reasons discussed below, the Board finds that this lay evidence is not credible. Thus, this opinion is not only inadequate but is also based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet.App. 458, 461 (1993). Therefore, the Board finds that the September 2012 private examination is not probative. The Veteran's representative also arranged for an October 2012 vocational consultation. The consultant opined that the Veteran's postservice mental health diagnoses are likely service connected because they did not exist prior to service. However, the consultant does not explain how her expertise as a vocational consultant qualifies her to competently opine on psychiatric diagnoses, and the record does not show that she has the training and expertise necessary to determine the etiology of the Veteran's psychiatric disability. Thus, the Board finds that the consultant is not competent to opine as to whether the Veteran's current psychiatric disability is related to his military service. To the extent that the consultant is qualified to opine as to the Veteran's ability to pursue gainful employment, such opinion is not relevant to a determination regarding entitlement to service connection, and the Board will not consider it further. Lay statements The record contains lay statements from the Veteran, his wife, his mother, and his former employer, Mr. D. B. Mr. D. B. states that he first hired the Veteran in 1989, at which point "[h]e was a great worker that follow[ed] orders and got along with everyone." Mr. D. B. stated that he hired the Veteran again in 1995, at which point the Veteran would not take orders and frightened the other employees such that they threatened to quit if they had to work with the Veteran. Mr. D. B. reports that the Veteran told him that his behavior was due to his treatment in the Navy. The Board first notes that Mr. D. B. apparently first hired the Veteran a year after the Veteran's discharge from service and that, at that time, the Veteran was a "great worker." This does not support the Veteran's contention that he has a chronic psychiatric disability dating back to his time in service. Mr. D. B. implies that he did not see the Veteran again until 1995, at which point the Veteran's personality had changed. Consequently, the Board finds that Mr. D. B. is not competent to evaluate the Veteran's mental health status between 1989 and 1995 and, thus, cannot provide competent evidence as to when the Veteran's chronic psychiatric disability began. The Board also notes that neither the Veteran, nor Mr. D. B., have established that they are competent to determine the etiology of psychiatric conditions. Therefore, this "buddy letter" is not competent evidence in support of the Veteran's claim. Furthermore, the Board notes that the record contains abundant treatment records from 1998 to 2005 and that neither the Veteran, nor his numerous treatment providers, relate his current chronic psychiatric disability to his military service. If, when he was hired by Mr. D. B. in 1995, the Veteran stated that he had a psychiatric disability resulting from his military service, the Board finds it reasonable that the Veteran would also have mentioned it over the subsequent seven years of psychiatric treatment covering at least three hospitalizations and at least two suicide attempts; he did not. Thus, the Board also concludes that Mr. D. B.'s statement is not credible evidence supporting the Veteran's claim. The Veteran's wife provided two statements - one received by VA in August 2010, along with the Veteran's notice of disagreement, and one received in January 2011. In her August 2010 letter, the wife described the Veteran's postservice symptoms, to include suicide attempts and hospitalizations. She did not mention the alleged in-service assault and stated: "I don't know what all happened" in boot camp. In her January 2011 letter, on the other hand, she described receiving a letter from the Veteran, threatening suicide due to "getting the crap beat out of [him]" and not being allowed to eat or sleep. While the Veteran's wife is competent to report symptoms she observed and recall letters she received, and while the record supports the wife's contention that she received a letter from the Veteran, in which he threatened suicide, the Board finds it reasonable that, if the wife was aware of the Veteran's alleged physical assault, and its asserted relationship to the Veteran's threats of suicide, she would have mentioned such in her August 2010 letter written to support the Veteran's notice of disagreement with his initial rating decision denying entitlement to service connection; she did not. Furthermore, the Board again notes that the Veteran's in-service October 1988 mental health examination was negative for any indication of a physical assault. Consequently, the Board finds that the wife's lay statements are not credible evidence supporting the Veteran's claim. The Veteran's mother also wrote a letter in January 2011, supporting the wife's testimony. The mother is also competent to report symptoms she observed and phone conversations in which she participated. The Board also notes that the record supports the mother's statement that she received a call from the then-fiancée, relaying the Veteran's threat of suicide if he did not "get out" of service, and that she relayed that message to the base where the Veteran was stationed. However, the Board again finds that the mother's assertion that the Veteran wrote that his suicide threat was due to in-service physical assault is not consistent with his long history of postservice mental health treatment, in which he discussed psychosocial and environmental factors such as his father's murder, sexual abuse, criminal legal difficulties, financial problems, and marital problems but did not discuss an in-service physical assault until he submitted his claim for entitlement to service connection for an acquired psychiatric disorder in 2010. The Board finds that the Veteran's statements, provided for the purpose of receiving mental health treatment following suicidal gestures and attempts, regarding the pre and postservice stressors in his life are more credible than the mother's statement, provided over 21 years following service and in support of her son's claim for compensation. Additionally, the Board notes that, in October 1988, the Veteran stated that he tells his mom that he is going to kill himself so that he will achieve his objective (i.e., get out of service), not as a result of actual suicidal ideation. Thus, the Board finds that the mother's statement relating her son's disability to an in-service physical assault is not credible. The Veteran provided statements with his August 2010 notice of disagreement and his January 2011 substantive appeal, statement in support of claim, and additional statement in support of his claim for entitlement to service connection for PTSD. In these statements, the Veteran reiterates that he was assaulted while in service, that his in-service threat of suicide was the result of such assaults, that his psychiatric symptoms are chronic and have persisted since service, and that all of his present difficulties, to include unemployment and legal, financial, and marital problems, are the result of said assault. First, while the Veteran is competent to report the symptoms he experiences, he is not competent to determine the etiology of his disability, as that requires medical knowledge. See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Therefore, the Board finds that the Veteran's statements are not competent evidence providing a nexus between his current psychiatric disability and his military service. Second, as previously discussed, the Board finds that the Veteran's statements regarding the onset of his current psychiatric disability, to include whether such disability began in service, are not credible. Also, as discussed above, the Board finds it reasonable that, if the Veteran had suffered an in-service personal assault, he would have included such assault in his history of outside stressors, as reported from 1998 to 2005. As he did not, and as there is no other competent, credible evidence in the record attesting to such an assault, the Board finds the Veteran's statements regarding an in-service physical assault are not credible. As the lay evidence of the record is not competent and credible evidence supporting the Veteran's claim, the private examinations and treatment records that rely on such evidence for their diagnoses are based on inaccurate factual predicates and are not probative. See Reonal, supra. Conclusion In sum, the Veteran's in-service October 1988 threat of suicide was due to an adjustment disorder, which was a temporary condition. (See April 2010 VA examination and September 2012 private examination.) Furthermore, such threats were consistent with the Veteran's history of manipulative interaction with his mother, and there is no indication in the Veteran's service treatment and personnel records that he was assaulted. The competent, credible evidence of record does not show that the Veteran received any mental health treatment between discharge and 1998. Private medical records from 1998 to 2005 document recurrent treatment for a psychiatric disability, to include suicidal gestures and attempts, related to the Veteran's history of family, financial, and legal troubles. Although in-service suicidal thoughts were noted as part of the Veteran's psychiatric history, at that time there was no assertion on the part of the Veteran or his treatment providers, that his current psychiatric disability was related to service. The first evidence asserting an in-service physical assault and relating the Veteran's psychiatric disability to service was the Veteran's claim for entitlement to service connection for a psychiatric disorder. The Board finds that such evidence, along with the other lay evidence of record, is not be competent and credible evidence in support of the Veteran's claim. As a result, medical evidence relying upon that lay evidence is not probative evidence in support of the Veteran's claim. See Cartright v. Derwinski, 2 Vet. App.24, 25 (1991) (finding that, while the Board may not ignore a Veteran's testimony simply because he or she is an interested party and stands to gain monetary benefits, personal interest may affect the credibility of the evidence); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). The April 2010 VA examination is probative evidence that the Veteran's psychiatric disability is not related to his military service. The January 2012 VA examination is probative evidence that the Veteran's self-reports of his psychiatric state are unreliable and cannot support a diagnosis of PTSD (or any other psychiatric disorder). The only other PTSD diagnoses of record are not probative because they are either based on the Veteran's noncredible and unreliable evidence or do not consider said diagnosis in conjunction with the relevant DSM-IV criteria. To the extent that the Veteran has any psychiatric disorder, despite several episodes of in-patient treatment associated with suicidal gestures and attempts, the competent and credible evidence of record is against a finding that his current psychiatric symptoms or diagnosis are related to service. The Board finds that the competent, credible evidence in this case weighs against a finding of any medical nexus between any current psychiatric disability and the Veteran's service. As the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, however diagnosed, the benefit-of-the-doubt rule does not apply and this claim is denied. See 38 U.S.C.A § 5107. ORDER The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs