Citation Nr: 1320555 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 09-40 323 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD) and, if so, whether service connection is warranted. 2. Entitlement to service connection for diabetes mellitus, Type II. 3. Entitlement to service connection for peripheral neuropathies of the bilateral upper and lower extremities, claimed as secondary to diabetes mellitus. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1969 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In that rating decision, the RO denied service connection for diabetes and diabetic peripheral neuropathies and declined to reopen a claim for service connection for PTSD. The Veteran timely perfected an appeal of the rating action. As relevant to the Veteran's application to reopen her claim of entitlement to service connection for PTSD, the Board notes that such claim was previously denied in a July 2004 rating decision. The July 2004 rating decision also denied service connection for major depression and anxiety. However, the Veteran has not requested that such claims be reopened. Moreover, the April 2009 rating decision on appeal only addressed her application to reopen her claim for service connection for PTSD. In this regard, the Board is cognizant that the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). However, in the instant case, the Board finds that the Veteran's claimed psychiatric disabilities of major depression and anxiety are more appropriately viewed as claims separate from the PTSD claim because they have been previously denied and the Veteran has not requested that such be reopened. In this regard, the Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that, for purposes of determining whether a new claim has been submitted under 38 U.S.C.A. § 7104(b), the "factual basis" of a service connection claim is the Veteran's disease or injury, rather than the symptoms of that disease or injury. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); see also Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996). Moreover, in Clemons, the Court determined that the scope of Boggs and Ephraim is limited to claims to reopen. Specifically, the Court stated that Boggs, as well as Ephraim, relies upon a diagnosis to define the scope of a claim only retrospectively after there has been a finding of fact based upon competent medical evidence. See Clemons, 23 Vet. App. at 8. In the context of section 5108 and requests to reopen, this accomplishes a balancing effect that preserves the finality of agency decisions while not precluding Veterans from pursuing claims based on evidence of injuries or diseases distinct from those upon which benefits have been denied. Id. Therefore, the Board finds that the Veteran's claimed psychiatric disabilities of major depression and anxiety are more appropriately viewed as separate claims from PTSD and, as she has not filed a claim to reopen them, they are not properly before the Board. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal. A review of the virtual file does not reveal any additional evidence pertinent to the present appeal. The issues of entitlement to service connection for diabetes and peripheral neuropathies of the bilateral upper and lower extremities are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. In a final July 2004 rating decision, the RO denied entitlement to service connection for PTSD. 2. Evidence added to the record since the July 2004 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for PTSD. 3. The Veteran's report of her alleged in-service stressors is not credible. 4. PTSD is not shown to be causally or etiologically related to any disease, injury, or incident in service. CONCLUSIONS OF LAW 1. The July 2004 rating decision that denied the Veteran's claim of entitlement to service connection for PTSD is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2004) [(2012)]. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for PTSD. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. The criteria for service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As the Board's decision to reopen the Veteran's claim of entitlement to service connection for PTSD is completely favorable, no further action is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations regarding that specific issue. In regard to the underlying claim for service connection PTSD, the VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Additionally, VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 38 C.F.R. § 3.304(f) (5). In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, an August 2008 letter, sent prior to the unfavorable rating decision, advised the Veteran of the evidence and information necessary to substantiate a claim for service connection for PTSD on the basis of military sexual trauma (MST) and of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. The letter also advised of her and VA's respective responsibilities in obtaining such evidence and information. Moreover, the letter provided the Veteran with VA Form 21-0781a, Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault, which complied with the notice provisions of 38 C.F.R. § 3.304(f). The letter also advised that she could submit evidence of behavior change(s) and other alternative forms of evidence to substantiate her claim. 38 C.F.R. § 3.304(f) (5); Dixon v. Derwinski, 3 Vet. App. 261, 263-264 (1992); 38 C.F.R. § 3.159(e). Relevant to the duty to assist, the Veteran's service treatment and personnel records, as well as VA and private treatment records, have been obtained and considered. As the Veteran informed a December 2008 VA examiner of the name of her alleged attacker, the Board has considered conducting further search for disciplinary records. However, as she has not reported that charges were filed or other action pursued, and has instead informed VA that the alleged assault was "swept under the rug" (see September 2003 statement), there is no indication any such search would yield additional records. Further, although the Veteran has informed VA health care practitioners that she has applied for disability benefits through the Social Security Administration (SSA), she has indicated her claim for benefits was based on disability of the wrists and there is no indication that the SSA records are pertinent to her claim for PTSD. See Golz v. Shinseki, 590 F. 3d 1317 (Fed. Cir. 2010) (holding that "there must be specific reason to believe [SSA] records may give rise to pertinent information to conclude that they are relevant"). The Veteran has not identified any additional relevant and outstanding records that have not been requested or obtained. The duty to assist also provides that VA will afford a claimant a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c) (4). A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service. 38 C.F.R. § 3.159(c) (4). The threshold for establishing the third element is low for there need only be evidence that "indicates" that there "may" be a nexus between the current disability and military service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Veteran was afforded a VA examination in December 2008 and an addendum opinion was obtained in March 2009. Neither the Veteran nor her representative has alleged that such examination, with the addendum opinion, is inadequate. Moreover, the Board notes that the VA examiner offered reasoned opinions based on interview with the Veteran, a review of the record, and a full examination. Moreover, she cited to the relevant evidence within the claims file and offered clear conclusions with supporting data and reasoned medical explanations. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Therefore, the Board finds that the examination report of record, with the addendum opinion, is adequate to adjudicate the Veteran's claim for service connection for PTSD such that no further examination is necessary. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini, 1 Vet. App. at 546; Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis New and Material Evidence Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). Additionally, 38 C.F.R. § 3.156(b) provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179 (2003); Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran has contended that she experiences PTSD as the result of in-service MST. Specifically, she has reported being assaulted by a fellow marine in late 1969 and that the assault resulted in a pregnancy that ended her time in the military. The Veteran's claim for service connection for PTSD was originally denied in a July 2004 rating decision in which the RO found that there was no credible supporting evidence that the in-service trauma occurred or that any incident of service resulted in any current mental health symptoms. In July 2008, the Veteran submitted a petition to reopen the claim. At the time of the July 2004 decision, the RO considered the Veteran's service treatment and personnel records as well as post-service treatment records. The Veteran was advised by VA of the rating decision and her appellate rights. However, no further communication regarding the claim of entitlement to service connection for PTSD was received until July 2008. Therefore, the July 2004 rating decision is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2004) [(2012)]. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b); however, in the instant case, such regulation is inapplicable as no evidence pertaining to the Veteran's claim for service connection for PTSD was received prior to the expiration of the appeal period stemming from the July 2004 rating decision. Since the July 2004 rating decision, additional evidence consisting of additional treatment records, lay statements, opinions from health care providers, and the report of a December 2008 VA examination, with March 2009 addendum, was added to the record. The newly received evidence includes medical evidence supportive of the Veteran's contention that she experience psychiatric symptoms as the result of her active duty service. The Board concludes that the evidence received since the prior final denial is new in that it was not previously of record. It is material because it relates to unestablished facts necessary to substantiate the Veteran's claim. Specifically, two letters, dated in August 2008 and September 2008, from a VA mental health nurse and clinical therapist assess the Veteran as having PTSD as the direct result of military sexual trauma. Additionally, the Veteran has provided additional detail about her alleged in-service assault, to include the name of the alleged attacker. Although she had previously contended that she experienced mental health symptoms as the result of MST, she had not provided as much detail about the alleged assault and there was no prior competent medical evidence linking her alleged in-service trauma to a currently diagnosed acquired psychiatric disorder. The Veteran's lay statements, as well as the August 2008 and September 2008 therapist's opinions, are presumed credible for the purposes of evaluating the application to reopen the claim for service connection. Justus, supra. Therefore, the Board finds that the new evidence tends to prove previously unestablished facts necessary to substantiate the underlying claim of service connection for an acquired psychiatric disorder. Consequently, the newly received evidence raises a reasonable possibility of substantiating the Veteran's claim. Accordingly, the claim of entitlement to service connection for PTSD is reopened. Service connection Reopening the Veteran's claim for service connection for PTSD does not end the Board's inquiry; rather, consideration of the claim on the merits is now required. As the AOJ has already considered the issue of entitlement to service connection on a de novo basis in the April 2009 rating decision and September 2009 statement of the case, and as the Veteran has had an opportunity to address the merits of her claim in written statements, the Board may proceed with a final adjudication of the merits of the claim because there is no prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 393 (1993). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the Veteran has not been diagnosed with a disease recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable. To establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f) . If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). See also 38 U.S.C.A. § 1154(b). However, in this case, the Veteran does not contend, and the probative evidence of record shows, that she was not in combat. As such, this presumption is not applicable. Recent amendments to the regulation have eliminated the requirement of evidence corroborating the occurrence of the claimed in-service stressor in claims in which PTSD was diagnosed in service and in some claims in which the claimed stressor is related to the claimant's fear of hostile military or terrorist activity. Specifically, 38 C.F.R. § 3.304(f) was amended during the course of the Veteran's appeal to read that if a stressor claimed by a Veteran is related to his fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. "Fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Here, the Veteran does not contend, and the probative evidence of record does not show, that she experience fear of hostile military or terrorist activity. As such, this presumption also is not applicable. Hall v. Shinseki, --- F.3d ----, 2013 WL 2450628 (C.A. Fed.). However, there also are special considerations for PTSD claims predicated on a personal assault. The pertinent regulation, 38 C.F.R. § 3.304(f)(5), provides that PTSD based on a personal assault in service permits evidence from sources other than the Veteran's service records which may corroborate his or her account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). VA's Adjudication Procedures Manual (M21-1MR) also identifies alternative sources for developing evidence of personal assault, including private medical records, civilian police reports, reports from crisis intervention centers, testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, and personal diaries or journals. M21-1MR, Part IV, Subpart ii, 1.D.17.g. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance, substance abuse, episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(5). VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. In addition, VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). It is important to note that, for personal assault PTSD claims, an after-the-fact medical opinion can also serve as the credible supporting evidence of the reported stressor. Patton v. West, 12 Vet. App. 272, 280 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service treatment records reflect that, upon clinical evaluation at her October 1968 enlistment examination, she was psychiatrically normal. In an associated Report of Medical History, she denied nervous trouble and stated that she was "in good health" and "never complain[s] of any sickness besides menstrual cramps." She was seen in August 1969 for complaints of painful menses and was diagnoses with severe dysmenorrheal. Later that month, she requested mental health consultation as a result of depression. She reported that she has "had in mind to take pill or to get pregnant to get out of [Parris Island]." Upon inspection, she threatened to commit suicide if not transferred off Parris Island to a different duty station. She was assessed as fit for duty and was noted to have a passive aggressive personality. In September 1969, she reported for treatment of bloody stools and was assessed as having constipation and mild hemorrhoids; inspection revealed no fissures. She was treated for an upper respiratory infection in October 1969 and, later that month, again reported rectal pain with bloody stools and was assessed as constipated. She received a rectal examination which revealed "no rectal pathology." Based on her symptom descriptions, she was assessed as experiencing menstrual pain. In December 1969, she reported for treatment of menstrual cramps, but was noted to not have any flow; a physical examination was unremarkable. Later that month, she again complained of menstrual cramps and requested to see a doctor rather than a nurse. Upon seeing the doctor, she also reported nausea. She was not seen again until mid-January. At that time, she was noted to have borderline enlargement of the uterus, "possibly." By the end of the month, a pregnancy, of approximately two months duration, had been confirmed. The Veteran's January 1970 discharge examination reflects that, upon clinical evaluation, she was psychiatrically normal. The Veteran's personnel records reflect certificates, awarded in June 1969 and October 1969, of courses completed in San Diego, California, and Washington, D.C., respectively, as well as several items of correspondence. The correspondence reveals that the Veteran was not pleased with her duty assignment to Parris Island. In August 1969, she wrote to the sergeant who recruited her and contended that she had not signed up for three years of active duty; she wrote that he had promised she would only have to serve two years rather than the three required by her enlistment paperwork. She requested that the sergeant "act now" to reduce her service time or she would contact her parents and "inform the commandant." She contended that "these people" (presumably other persons stationed at Parris Island) "are against blacks." In September 1969, she wrote to her senator and requested assistance - she informed the senator that she had been promised a term of only two years active duty as well as an 'area option,' but had not received either. The Veteran reported that she "can't cope with this southern treatment" and asked if the senator could assist her in either a transfer or a discharge because, as a trip to a psychologist had been unsuccessful, her only other "way out of the marines is get pregnant." Subsequent to congressional inquiry, the military conducted an investigation and gathered statements from the recruiting sergeant, another sergeant at the recruiting station, as well as the officer in charge of the recruiting station. The recruiting sergeant wrote in a September 1969 statement that he had properly informed the Veteran prior to her enlistment that the minimal service requirement was 2 years of active with 1 year reserve, but she had requested 3 active and 1 reserve. He also stated that he had advised her that no area option was available. The recruiting sergeant stated that the Veteran visited him while home on leave after basic training and had informed him that he wanted to "get out of Parris Island even if she had to get pregnant." The other sergeant wrote a statement verifying that appropriate procedures had been followed in regard to the Veteran's enlistment and that she had been fully advised. The officer in charge issued a statement to the commandant reflecting that appropriate enlistment procedures had been followed in regard to the Veteran's enlistment. She wrote again to the recruiting sergeant in October 1969 and again contended that he had "promised" she would only serve two years and reminded him that she had "joined for [him], not [her]." She again requested that he take action on her behalf. The Veteran also wrote again to the senator in October 1969, contended that she had been misled, and again asked for assistance. The Brigadier General of the Marine Corps wrote to the Senator in November 1969 and attested that all appropriate procedures had been followed in regard to the Veteran's enlistment. The last item of correspondence within the claims file is a January 1970 letter from the Veteran's commanding officer to her parents; the letter informs them that the Veteran was being discharged due to pregnancy. Post-service private treatment records reflect that the Veteran was treated in May 1970 for gonorrhea and gave birth in August 1970. She subsequently used birth control, but, in November 1971 was diagnosed with another pregnancy. She did not complete that pregnancy and became pregnant again in early 1972. Despite February 1972 treatment of the third pregnancy, she was diagnosed with incomplete abortion in April 1972. A September 1977 note reflects that she reported possible exposure to venereal disease and was treated for "probable" gonorrhea prior to diagnosis of candida with inflammation. An August 2003 private treatment note reflects that the Veteran reported feeling anxious and depressed and informed her physician that "she was in Vietnam War for 2 years." The physician assessed anxiety, depression, and "? PTSD," and noted that the Veteran reported that she would be evaluated by VA. An August 2003 VA treatment note reflects that the Veteran reported experiencing some sexual harassment while in the military as well as verbal and physical abuse by her father prior to her military service. In September 2003, the Veteran wrote to VA and contended that she experienced PTSD, anxiety, and major depression as a result of sexual harassment and rape during her active duty service. She stated that the incidents were "swept under the rug," but the rape resulted in her pregnancy and discharge from the service. In the statement, the Veteran avers that the alleged MST affected her post-service life, preventing her from experiencing love and marriage. She specifically contended that she "certainly cannot be physically intimate with anyone" as a result of the MST. A September 2003 note from the Veteran's private physician reflects that she reported having been diagnosed with PTSD at a VA Medical Center (VAMC). September 2003 VA treatment notes reflect that the Veteran reported treatment by her private physician. A November 2003 VA mental health treatment note states it was her "first visit" to the VA mental health center. The VA psychiatrist noted her reports of verbal and physical abuse by her father as well as of an in-service rape; she informed the psychiatrist that she was not in a relationship and had never married because she could not trust a man. The psychiatrist diagnosed her with chronic PTSD and generalized anxiety disorder. A January 2004 VA treatment note reflects that the Veteran was "distressed about sexual side effects" of Paxil and specifically complained of a poor sex drive and inability to climax. A June 2004 VA mental health treatment note reflects no change in her diagnoses. The Veteran's initial claims for service connection for anxiety, depression, and PTSD were denied in July 2004. She was seen in January 2005 for complaints of worsening anxiety and she informed the practitioner that she wanted to retire early from work due to job stress. In March 2005, no symptom worsening was noted and her problem list reflects anxiety disorder as her only mental health diagnosis. This diagnosis is reflected in subsequent problem lists and, in July 2008, the Veteran submitted a new claim of entitlement to service connection for PTSD. She wrote that she experienced harassment and rape by a sergeant while she was stationed at Parris Island. She wrote that, as a result, she became pregnant and was discharged and subsequently could not "stand to be around others especially of the male gender." An August 2008 VA report of telephone contact reflects that the Veteran called, reported experiencing depression, and requested to see a particular VA mental health clinician who she had not seen in "a few years." She was seen later that same month; the note reflects that she was again requesting treatment for symptoms she attributed to an MST. The Veteran wrote to VA in August 2008 and described her alleged in-service assault. A VA clinical therapist submitted an August 2008 letter on her behalf stating that she was treated for MST-related PTSD. The following month, the therapist wrote again and more specifically attributed the Veteran's "severe PTSD" to the alleged MST. An October 2008 VA mental health treatment note reflects diagnoses of depression and anxiety; she reported stress about her employment. In December 2008, the Veteran was afforded a VA mental disorders examination. She informed the examiner that her father was "quite volatile, both verbally and physically" and that she had been assaulted during her active duty service. She reported that she was single, found relationships difficult, and felt uncomfortable around men. Although the Veteran attributed those symptoms to the alleged in-service MST, the examiner noted that they could also be attributed to childhood abuse by her father. She denied that any mental health symptoms affected her work and stated that any work impairment was the result of physical disabilities. The Veteran also informed the examiner that her daughter maintains contact with her father (i.e., the alleged rapist). Following clinical testing, the Veteran was diagnosed with PTSD. The examination report reflects a detailed summary of the Veteran's claims file with citation to multiple documents within her service record. The examiner concluded that, although MST was possible, the Veteran's current mental health symptoms are more likely than not attributable to childhood abuse. The examiner explained that the claims file does not reflect, prior to the time the Veteran made her initial claim, that any MST occurred and that, based on conference with a clinician with over a decade of experience in treating MST, the Veteran's reaction thereto (to include allowing the perpetrator to maintain a relationship with her/his daughter) was not typical. An addendum opinion was issued in March 2009 and reflects that the examiner reviewed private medical evidence added to the record after the December 2008 examination. The examiner observed that the records showed that the Veteran was treated for sexually transmitted disease during and after her initial pregnancy and then became pregnant again. The examiner again discussed the in-service evidence, commented on the correspondence indicating that the Veteran planned to get pregnant during service in order to obtain a discharge, and noted that the post-service private medical evidence clearly reflected that she had not, as she had contended, avoided all sexual contact after the alleged MST. The examiner again determined that, although the Veteran has PTSD, it was attributable to her childhood experiences rather than any in-service experience. Despite the December 2008 and March 2009 diagnoses of PTSD, a May 2009 VA treatment note reflects that the Veteran's only mental health diagnosis was anxiety. The treating physician noted that one of her prescription medications could have been contributing to that diagnosis. Subsequent notes continue to reflect diagnosis and treatment of depression and anxiety disorder. The Veteran is competent to report that she experienced her alleged stressors - harassment and assault at the hands of a single sergeant whom she identified by name to the December 2008 VA examiner - in service, and that she has experienced psychiatric symptoms since such time. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (holding that a claimant was competent to testify to chronicity and continuity of mental health symptoms); Culver v. Derwinski, 3 Vet. App. 292, 297-98 (1992) (holding that a claimant was competent to report a nervous breakdown that occurred shortly after service). Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, the Board finds that the Veteran's lay statements regarding the account of her alleged stressors to be not credible, as described below. In addition to evaluating competence, the Board has a duty to assess the credibility of the evidence of record. Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Although the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence of the in-service event -see Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006)- the Board may discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this regard, the Board finds that the credibility of the Veteran's allegations pertaining to her in-service stressors is outweighed by the evidence to the contrary, which includes competent and probative medical opinion evidence and her own documented falsehoods. First, the credibility of the Veteran's account is diminished by the medical evidence of record plainly showing that she was sexually active during her first pregnancy and thereafter. Specifically, although she contended on multiple occasions that the in-service MST left her unable to be close to, or physical with, another person, she was treated for sexually transmitted diseases during and after her first pregnancy, had a subsequent pregnancy, and was, according to VA treatment notes, very concerned in 2004 that a prescription medication had decreased her sex drive. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). Second, the Board finds that the Veteran's account of her alleged stressors lack credibility because she provided inaccurate statements to her health care professionals near the time she filed her initial claim for benefits. Specifically, in 2003, she informed her private physician that she experienced anxiety and depression as the result of her service in the "Vietnam War for 2 years." However, the record plainly reflects that the Veteran was not in the service for 2 years and never served outside of the continental United States. Further, a September 2003 private treatment note specifically states that she reported having received a VA diagnosis of PTSD, but no such diagnosis was rendered until November 2003. Third, although the Veteran's claims file does contain some of the forms of alternative evidence that can be used to support a contention of MST, 38 C.F.R. § 3.304(f)(5), none of that evidence actually supports her contentions. Rather, service personnel records show that she successfully completed two courses in June 1969 and October 1969. Letters she wrote during service reflect that she was concerned about racial, rather than sexual, tension. Moreover, they reflect that she desired an early discharge from the military and informed at least two persons that she considered pregnancy as a possible course of action. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). Here, the record also reflects that, at approximately the same time the Veteran filed her claim for benefits, she desired monetary gain that would enable her to retire from her employment. Further, she has made statements about her symptoms and her past that are plainly contradicted by the evidence of record. Probative medical evidence also indicates that her mental health symptoms are less likely than not attributable to any in-service experiences. Although the Board notes that a VA clinical therapist has written letters attributing the Veteran's mental health symptoms to MST, the record does not reflect that therapist was aware of her documented post-service medical history reflecting subsequent sexual activity and pregnancies. Nieves-Rodriguez, supra, at 300 (a physician's knowledge of relevant case facts bears on the probative value assigned to a medical opinion). When faced with conflicting medical opinions, the Board must weigh the credibility and probative value each of the opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez, supra. Initially, the Board will assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. Here, only the VA examiner reviewed the claims file, but review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a Veteran. Id. at 303-04. However, here, it does not appear as though the clinical therapist had a factually accurate medical history of the Veteran as treatment records reflect that she reported having been unable to be intimate with a man after, and as a result of, the alleged MST. Second, the Board will consider whether or not the medical expert provided a fully articulated opinion. Id. Finally, the Board considers whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez, supra; Stefl, supra. Here, the clinical therapist did not have access to a factually accurate history and she also did not provide a fully articulated opinion. In contrast, the VA examiner discussed the Veteran's account of the MST and her account of subsequent symptoms; the examiner also provided an analysis of her past and current symptoms in regard to etiology. In contrast, the therapist simply attributed PTSD to the alleged MST without further explanation or analysis. See Nieves-Rodriguez, supra; Stefl, supra. For these reasons, the Board finds the opinion of the VA examiner most probative. Evans, 12 Vet. App. at 30; Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999). The Board has considered the Veteran's lay statements that her mental health disorders are related to her military service, but finds that, as a lay person, she is not competent to render an etiological opinion. In this regard, the question of etiology of a mental disorder involves a medical subject concerning an internal psychological process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is non-probative evidence. See Jandreau, supra; see also Woehlaert, supra. The Board also notes that the Veteran has repeatedly reported, and multiple health care practitioners have observed, that she may experience a current acquired psychiatric disorder as the result of childhood experiences. Although such evidence may be viewed as raising an aggravation (of pre-existing condition/injury) theory of entitlement to service connection, the Board has determined that there is no competent and credible evidence of an in-service stressor (i.e. an aggravating occurrence). Further, and also as observed above, there is no credible evidence of a mental disorder existing prior to 2003. Therefore, the Board finds that service connection is not warranted for the Veteran's PTSD. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER New and material evidence has been received, and the appeal to reopen a claim of entitlement to service connection for PTSD is granted, to this extent only. Service connection for PTSD is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims for service connection for diabetes and neuropathies of the bilateral upper and lower extremities so that she is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Initially, the Board finds that a remand is necessary in order to obtain private treatment records. In this regard, the Veteran has informed VA health care providers that she has undergone nerve studies of her wrists at Kentucky Physical Medicine and "OSH." Although VA treatment notes contain summaries of some such nerve studies, the AOJ should attempt to obtain all such private medical records on remand. The AOJ should also seek clarification from the Veteran as to the potential relevance of records from her employer, Verizon. She has informed various VA healthcare providers that she experiences wrist and hand disabilities that interfere with her employment and the claims file reflects that she filed a worker's compensation claim and has received employment disability benefits through MetLife. The AOJ should advise her that such employment records could be relevant to the issues currently under consideration. See Spurgeon v. Brown, 10 Vet. App. 194, 197-98 (1997). Additionally, while on remand, updated VA treatment records should be obtained. Specifically, the file reflects that that the Veteran receives ongoing care from the VA Medical Center in Lexington, but only VA treatment records dating up to September 21, 2009 are associated with the record. Outstanding VA treatment records should be obtained and incorporated into the claims file before appellate review proceeds. Review of the claims file also shows that the Veteran has applied for Social Security disability benefits as the result of wrist and hand disabilities. However, the claims file does not reflect evidence of a decision regarding this award or that VA has otherwise contacted SSA to obtain any of the medical records used in such a determination. The Board finds that there is a reasonable possibility that records held by the SSA could help the Veteran substantiate her claim. See Golz, 590 F.3d at 1323. Hence, on remand, the AOJ should attempt to obtain any available SSA records. The Board also finds that a remand is necessary to afford the Veteran a VA examination and opinion so as to determine the nature and etiology of her diabetes mellitus and any complications thereof, to include the alleged peripheral neuropathies. Specifically, a VA examination is required because the Veteran has presented evidence of diagnosis of diabetes mellitus and the record reflects that she experienced gestational diabetes as part of a pregnancy incurred in service. As she has also contended, and cited medical research indicating, that gestational diabetes can lead to subsequent development of diabetes mellitus, a medical opinion is warranted. McLendon, 20 Vet. App. 79. Additionally, the Veteran has not been provided with proper VCAA notice regarding the secondary aspect of her claim of entitlement to service connection for peripheral neuropathy. Such should be accomplished on remand Accordingly, the case is REMANDED for the following action: 1. The Veteran should be provided with proper VCAA notice regarding the evidence and information necessary to substantiate her claim of entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities as secondary to diabetes mellitus. 2. Obtain all available VA treatment records dated after September 21, 2009. NOTE that the Veteran has reported being treated at the VA Medical Center in Lexington, Kentucky. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Provide the Veteran with an opportunity to submit any additional private medical evidence that is not of record. Send her the necessary authorizations for the release of any private treatment records not currently on file - the records must include, but are not limited to, records from Kentucky Physical Medicine and "OSH." Make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford her an opportunity to submit any copies in her possession. 4. Concurrent with the above, advise the Veteran that records from her employer as well as MetLife may be pertinent to her claims. The AOJ should assist her in obtaining any such pertinent evidence following the current procedures set forth in 38 C.F.R. § 3.159. 5. Contact the Social Security Administration and obtain any administrative decisions and all medical records used in adjudicating the Veteran's claim for disability benefits. Any records obtained should be associated with the claims file. If these records are unobtainable, a negative reply must be noted in writing and associated with the claims file. 6. After all outstanding records have been associated with the claims file, the Veteran should be afforded an appropriate VA examination to determine the current nature and etiology of any current diabetes mellitus and complications thereof. The claims file, to include a copy of this Remand, must be made available to, and be reviewed by, the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's diabetes mellitus began during service or is otherwise causally related to any incident of service, to include her in-service pregnancy. The examiner should also indicate whether the Veteran had diabetes mellitus within one year of her service discharge in January 1970 and, if so, describe the manifestations. In offering any opinion, the examiner must consider the full record, to include the Veteran's service treatment records, post-service treatment, and contentions as well as her authorized representative's citation to research from the Mayo Clinic and the National Institutes of Health. See May 2013 brief, stating "women with unmanaged gestational diabetes are at increased risk of developing Type 2 diabetes mellitus." The rationale for any opinion offered should be provided. If determining that the Veteran's diabetes is etiologically related to any incident of her active duty service or manifested within one year of her January 1970 discharge, the examiner also must determine whether it is at least as likely as not that she has peripheral neuropathy of the bilateral upper and lower extremities or not she experiences any peripheral neuropathies as a result of diabetes. The examiner should also provide an opinion as to whether her diabetes has resulted in, or aggravated (beyond a natural progression), carpal tunnel syndrome, as indicated by November 2008 and July 2009 VA treatment notes. The rationale for any opinion offered should be provided. 7. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs