Citation Nr: 1320844 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 03-29 056 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD S. B. Mays, Counsel INTRODUCTION The Veteran had active military service from December 1965 to October 1969 and from August 1972 to August 1974. The appeal to the Board of Veterans' Appeals Board) is from an October 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that, in relevant part, determined that new and material evidence had not been received to reopen this claim of entitlement to service connection for PTSD. Although the Veteran initially requested a hearing at the RO before a local Decision Review Officer regarding his petition to reopen this claim, he later opted for an informal conference instead. A May 2004 conference report is of record and has been reviewed. In a June 2005 decision the Board concluded there was the required new and material evidence and, therefore, reopened this claim. See 38 C.F.R. § 3.156(a). But rather than immediately readjudicating this claim on its underlying merits, the Board instead then proceeded to remand this claim to the RO via the Appeals Management Center (AMC) for further development and consideration. The AMC subsequently continued to deny the claim on its underlying merits (i.e., following a de novo review of the evidence) in an August 2007 supplemental statement of the case (SSOC) and returned the file to the Board for further appellate consideration. In July 2009, the Board requested and obtained an independent medical expert (IME) opinion. The Board subsequently issued a decision in February 2010 denying service connection for an acquired psychiatric disorder inclusive of but not limited to PTSD. The U. S. Court of Appeals for Veterans Claims (Court/CAVC) had held that the scope of a claim for service connection for a mental disability includes any mental disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009); see also Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009) (A claimant's identification of the benefit sought does not require any technical precision), citing Ingram v. Nicholson, 21 Vet. App. 232, 256-57 (2007) (It is the pro se claimant who knows what symptoms he is experiencing and that are causing him disability); see, too, Robinson v. Nicholson, 21 Vet. App. 545, 552 (2008) (The Board is required to consider all issues raised either by the claimant or the evidence of record). The Veteran appealed the Board's decision denying his claim to the Court (CAVC). In a December 2010 Order, granting a Joint Motion, the Court vacated the Board's decision and remanded the claim to the Board for further development and readjudication in compliance with directives specified. And to comply with the Court's Order, the Board in turn again remanded this claim to the RO via the AMC in June 2011. But because the additional development of the claim requested in that remand was not completed, the Board again remanded the claim in April 2012 with the hope of completing the further development of the claim the Court-granted Joint Motion had indicated was necessary before readjudicating this claim. But still, in February 2013, the Board determined that yet another remand was necessary to complete the development previously directed by the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (requiring the Board to ensure compliance with its prior remand directives). This additional development fortunately since has been completed and the file returned to the Board for further appellate consideration. FINDINGS OF FACT 1. The Board remanded this case to the RO via the AMC, in part, to schedule the Veteran for a VA mental status examination to obtain a medical nexus opinion indicating the likelihood that that any current psychiatric disorder was incurred in or aggravated by his active military service and whether his personality disorder "clearly and unmistakably" preexisted his service and, if so, the likelihood that any of the several additional diagnoses since service are indication of disability superimposed upon the personality disorder and, in turn, the result of his military service. 2. Although scheduled for this examination in May 2012, June 2012, and again in April 2013, he failed to report and has not explained his absence or requested to reschedule the examinations, in turn requiring consideration of his claim based on the medical and other evidence already on file. 3. The preponderance of the probative medical and other evidence of record does not establish he has PTSD or any other mental disorder, including a personality disorder, attributable to his military service or that was permanently worsened by his service. CONCLUSION OF LAW It is not shown he has an acquired psychiatric disorder, including PTSD, as a result of disease or injury incurred in or aggravated by his active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304(f), 3.655(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In deciding this claim, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist obligations. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative of any information and any medical or lay evidence that is necessary to substantiate the claim, including apprising them of the information and evidence the Veteran is responsible for providing versus the information and evidence VA will obtain for him. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate or incomplete, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated, rather preserved, and the Veteran is given ample opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate effectively in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). He was provided VCAA notice in August 2002, prior to the RO's initial adjudication of the petition to reopen his claim in October 2002, so in the preferred sequence. That notice addressed the issue of whether new and material evidence had been received to reopen his previously denied service connection claim for PTSD. Once the Board reopened this claim upon finding there was the required new and material evidence, additional VCAA notice letters were sent to him in June 2005, February 2007, May 2012, February 2013, March 2013, and April 2013. After all notice was provided to him, his claim was readjudicated on its underlying merits in a May 2013 SSOC. And as for the Dingess requirement that he also receive notice concerning the "downstream" disability rating and effective date elements of his claim, since the Board is denying his underlying claim for service connection, the downstream disability rating and effective date elements of his claim are ultimately moot. Therefore, failure to provide notice concerning these downstream elements of his claim is non-prejudicial, i.e., harmless error. See 38 C.F.R. § 20.1102. As for the duty to assist him with his claim, the RO and AMC obtained his service treatment records (STRs), service personnel records (SPRs), medical treatise articles, private medical evidence, and VA medical evidence - including the reports of his May 1994, April 2007 and May 2007 VA Compensation and Pension Examinations (C&P Exams) addressing the nature and etiology of his asserted psychological condition, the dispositive issue in this appeal. In addition to those C&P exams, the Board obtained the July 2009 IME opinion for further medical comment concerning whether he meets the requirements for a diagnosis of PTSD and, if determined he does, whether it or other mental illness diagnosed is a result of his military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C.A. § 5103A(d)(2) and 38 C.F.R. § 3.159(c)(4). Also, pursuant to the June 2011 remand, the RO/AMC was directed to contact him and ask that he update the list of the doctors and mental health care facilities that had treated him for his psychiatric disorders, regardless of the specific diagnosis. These records were to include, but were not limited to, those concerning any psychiatric evaluation or treatment, such as for PTSD, at the local VA Medical Center (VAMC) in Columbia, South Carolina. And upon receiving his response, the RO/AMC was to obtain all additional medical treatment records. Additionally, the RO/AMC was to schedule a VA compensation examination for additional comment on the likelihood (very likely, as likely as not, or unlikely) that any current psychiatric disorder was incurred in or aggravated by his military service from December 1965 to October 1969 and from August 1972 to August 1974. The Board defined the term "as likely as not" and, in regards to the personality disorder, indicated it was to be determined whether it "clearly and unmistakably" had preexisted the Veteran's service and, if so, the likelihood (very likely, as likely as not, or unlikely) that any of the several additional diagnoses since service are indication of disability superimposed upon the personality disorder and, in turn, the result of his military service or, instead, more likely the result of other unrelated factors. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. See also VAOPGCPREC 82-90 (July 18, 1990), 55 Fed Reg. 45,711; Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); Quirin v. Shinseki, 22 Vet. App. 390 (2009); and Winn v. Brown, 8 Vet. App. 510, 516 (1996). This development requested in the June 2011 remand was not completed because of the AMC's inability to contact the Veteran and obtain necessary information from him - but apparently because of using an incorrect address - so the Board remanded the claim again in April 2012. In December 2012, the Board received correspondence from the Veteran listing his objections to and/or errors in the handling of his appeal. The problems addressed included his submission of VA Form 21-4142 authorizing VA to obtain his confidential medical treatment records. The second point he raised in his letter concerned the VA examination that was scheduled for June 8, 2012. He stated that his reason for not reporting for that examination was that being questioned in a small room triggered his PTSD symptoms since it reminded him of his "SERE" training, which was one of his PTSD stressors. Earlier letters dated May 14, 2012 and June 13, 2012, also expressed his objections to scheduled VA examinations. In the first letter he pointed out that the Board's April 2012 remand instructions stated the examination was to be scheduled after obtaining additional records and, therefore, that the May 2012 VA examination was premature. For this reason, he did not report for the May 2012 VA examination. In a June 1, 2012 response, the AMC stated that the scheduling of that May 2012 VA examination was not in error as it was their practice to schedule examinations as soon as possible. The Veterans Service Center Manager added that, if the Board felt that it was mandatory for the collection of evidence prior to the VA examination, then the remand would have stated, "After the evidence/records have been received, then and only then schedule the Veteran for an examination". On June 8, 2012, the Veteran was notified of another VA examination for which, as noted, he also failed to report, so again was a "no-show". In the letter received in December 2012, the Veteran also objected to the need for another VA compensation examination, noting there are at least two PTSD diagnoses in the record relating this condition to his military service. In the Joint Motion, however, the Board was specifically advised to determine whether a new medical opinion was necessary to decide the claim, which it had done and concluded was indeed needed. While the record as alleged contained evidence favorable to the claim, there also was evidence against the claim. In Mariano v. Principi, 17 Vet. App. 305 (2003), the Court indicated it "would not be permissible for VA to undertake such additional development if a purpose was to obtain evidence against an appellant's case." See Mariano, at 312. But the Court distinguished Mariano in Douglas v. Shinseki, 23 Vet. App. 19 (2009). In Douglas, the Court acknowledged its decision in Mariano, but held that VA may undertake the development of additional evidence if, as here, it is necessary to render an informed decision on the claim. Douglas, at 26. The Veteran has had a long and complicated psychiatric history, which in the Board's estimation required an additional opinion that included consideration of all available pertinent records. Indeed, the Joint Motion had directed the Board to undertake additional development and recognized that such development could necessitate the need for another examination. Following and as a result of the Board's February 2013 remand, an additional VA examination was scheduled for April 2013, but the Veteran again was a no show. In the file is a copy of the letter sent to him notifying him of that scheduled VA examination and confirms the letter was sent to his current address. There is a presumption of administrative regularity under which it is presumed that government officials "have properly discharged their official duties." See United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926); Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994) (VA need only mail notice to the last address of record for this presumption to attach). This presumption of regularity in the administrative process may be rebutted only by "clear evidence to the contrary." Schoolman v. West, 12 Vet. App. 307, 310 (1999). Moreover, even omission of an examination notification letter in a claims file, which, again, is not the situation here, will not rebut this presumption where VA's regular practice does not include retaining a hard copy of the letter in the claims file. See Kyhn v. Shinseki, 23 Vet. App. 335 (2010). Pursuant to 38 C.F.R. § 3.655, when a Veteran fails to report for a VA examination or re-examination that is scheduled in conjunction with an original claim, and he fails to provide good cause for this failure to report, the claim shall be rated based on the evidence of record, and as such, could result in denial of the claim. See 38 C.F.R. § 3.655(b). In this case, the Veteran failed to report for the scheduled April 2013 examination, and he did not provide any explanation or justification for his failure to report for that necessary medical evaluation. As such, his claim will be decided based on the existing evidence of record. See 38 C.F.R. § 3.655(b). In making this determination, the Board points out that the duty to assist is not a one-way street; a claimant cannot stand idle when the duty to assist is invoked by failing to provide important information or otherwise failing to cooperate. Wood v. Derwinski, 1 Vet. App. 190 (1991) (aff'd on reconsideration, 1 Vet. App. 460 (1991)); Olson v. Principi, 3 Vet. App. 480, 483 (1992). The Board notes further that, pursuant to the most recent remand, the Veteran completed updated authorization and consent forms. In response to a request for records, the Howard Center (D.W. Meyer) indicated it had no information to send concerning the Veteran. Further, Dr. B.Z. and Dr. L.L. did not respond to the AMC's recent records request; the Veteran was advised of this in the April 2013 VCAA notice letter but did not provide any additional information or evidence. 38 C.F.R. § 3.159(c)(1) and (e)(1). The Board thus finds that any further attempts to request records from Drs. B.Z. L.L. would be futile and, therefore, unjustified. Given all that has occurred, it is difficult to discern what additional guidance VA could have provided him regarding what further evidence he should submit to substantiate his claim. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."). See also Reyes v. Brown, 7 Vet. App. 113, 116 (1994) and Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not serve any useful or meaningful purpose or result in any significant benefit to the Veteran). This is especially true in light of the number of times this claim already has been remanded. For these reasons, the Board is satisfied there was compliance with its February 2013 remand directives - certainly substantial compliance and to the extent reasonably permissible. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Veteran has not identified, and the record does not otherwise suggest, any additional existing evidence that is necessary for a fair adjudication of this claim that has not been obtained and that is obtainable. In fact, in response to the latest SSOC, he indicated in May 2013 that he had no additional evidence regarding his appeal and asked that his case be forwarded to the Board immediately. No further notice or assistance to him with the claim therefore is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Whether the Veteran is Entitled to Service Connection for a Psychiatric Disorder, Inclusive of but not Limited to PTSD a. Legal Criteria - Service Connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for a disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a relationship or correlation between the disease or injury in service and the present disability - the so-called "nexus" requirement. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247, 252 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection for PTSD, in particular, requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., DSM-IV); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). A "clear" diagnosis of PTSD is no longer required. Rather, as mentioned, a diagnosis of PTSD need only be in accordance with 38 C.F.R. § 4.125(a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). See 38 C.F.R. § 3.304(f). The DSM-V (the latest version of the DSM) has now been officially released. However, 38 C.F.R. § 4.130 still explicitly refers to the DSM-IV. The regulation legally requires to continue considering this prior version of the DSM until such time as the regulation is changed. There is a regulation change in the works that would change the regulation to reference "the current version of the DSM." However, it is unclear when that proposed change will be published. Regardless, the Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) essentially have agreed that their target for moving to DSM-V is October 1, so by the beginning of the new fiscal year. So, for now, the regulation still explicitly refers to the DSM-IV, regardless of the fact that one may begin seeing private evidence referring to criteria under the DSM-V. The Court has taken judicial notice of the mental health profession's adoption of the DSM-IV as well as its more liberalizing standards to establish a diagnosis of PTSD. The Court acknowledged the change from an objective "would evoke . . . in almost anyone" standard in assessing whether a stressor is sufficient to trigger PTSD to a subjective standard (e.g., whether a person's exposure to a traumatic event and response involved intense fear, helplessness, or horror). Thus, as noted by the Court, a more susceptible person could have PTSD under the DSM-IV criteria given his or her exposure to a traumatic event that would not necessarily have the same effect on "almost everyone." Cohen, 10 Vet. App. 128, 140-141 (1997). Additionally, claims for certain "chronic" diseases - namely, those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b) by allowing a Veteran to show evidence of continuity of symptomatology since service as an alternative means of linking his currently claimed disability to his service. A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as "chronic" under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Psychoses are among the conditions in this VA regulation considered to be chronic, per se, and therefore subject to this alternative pleading and proof exception. Psychoses also will be presumed to have been incurred in service if manifested to a compensable degree of at least 10-percent disabling within one year after service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). According to 38 C.F.R. § 3.384, a "psychosis" includes the following specific disorders: brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. Thus, service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Generally speaking, personality disorders are "defects" that are not "diseases" or "injuries" within the meaning of applicable legislation for VA disability compensation purposes and, therefore, cannot be service connected. 38 C.F.R. §§ 3.303(c), 4.9, 4.127 (2012). Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90 (July 18, 1990). Congenital or developmental "defects," such as a personality disorders, automatically rebut the presumption of soundness and therefore are considered to have preexisted service. 38 C.F.R. §§ 3.303(c), 4.9; Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that the Secretary's exclusion of personality disorders from "diseases" or "injuries" as a congenital or developmental defect, such that the presumption of soundness does not apply, to be a valid exercise of the authority granted to the Secretary). As such, "[s]ervice connection of personality disorders, whether on a direct basis or by aggravation, is...prohibited...." 61 Fed. Reg. 52,695. However, 38 C.F.R. § 4.127 provides that disability resulting from a mental disorder that is superimposed upon a personality disorder may be service connected, and, in accordance with 38 C.F.R. § 3.310(a), personality disorders that result from service-connected disabilities may be service connected on a secondary basis. See also VAOPGCPREC 82-90 (July 18, 1990) (noting that congenital and developmental defects can be subject to superimposed disease or injury such that service connection may be granted where the superimposed disease or injury occurs during service); 61 Fed. Reg. 52,695 (explaining that "except as provided in § 3.310(a) in this chapter", § 4.127 was added for reinforce the principle that organic personality disorders that develop secondary to head trauma, epilepsy, etc., will be service connected secondary to these conditions). Therefore, while 38 C.F.R. §§ 3.303(c), 4.9, and 4.127 prohibit any grant of service connection for a personality disorder, even if aggravated in service, the Veteran's other diagnosed psychiatric disorders may provide a basis for service connection if the evidence shows these disorders were unrelated to or superimposed upon his diagnosed personality disorder. The first and indeed perhaps most fundamental requirement for any service-connection claim is there must be competent and credible evidence of the existence of the currently claimed disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). In its determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board must assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit Court, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id., at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Veterans Court (CAVC) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996). b. Factual Background & Analysis Turning now to the relevant facts of this case, a psychiatric disorder was not noted during the Veteran's military induction examination in August 1965, or during his re-enlistment examination in August 1972. STRs covering both periods of his service show no psychiatric complaints, treatment, or diagnoses. His second period of service ended in August 1974. A post-service summary report reveals that he was committed for 60 days to Central State Hospital for a pre-sentence evaluation from August to October 1975, so during the following year. Diagnoses were passive-aggressive personality, other sexual deviation, and adjustment reaction to adult life. From July to September 1976, he was admitted to a VA Hospital from the Milwaukee County House of Corrections. At that time, he complained of tenseness and depression which he related to his sexual deviation. He believed his main problems were related to being an orphan. Diagnosis was passive-aggressive personality. Thereafter, in August 1980, he was admitted to Vermont State Hospital due to a drunk driving/ hit-and-run accident, as well as threatening the police. The report indicates that he appeared psychotic and dangerous. A questionable diagnosis of schizophrenia, paranoid type, was rendered. In November 1984, he was admitted to a VA hospital because he was determined to be a threat to himself and the police. Final diagnosis was antisocial personality disorder. In March 1989, he was referred to VA for neuropsychological screening. For verbal intelligence, he tested at the high end of the average range. Testing also showed significant level of depression. There was no indication of organic impairment. According to a June 1990 statement from P.S.L., Ph.D., the Veteran was referred to a VA Medical Center for assessment of appropriateness for inclusion in the PTSD program, as well as for outpatient treatment for his sexual problems. Observation, interview, and testing did not substantiate a diagnosis of PTSD and he therefore was not accepted into the PTSD program. Rather, he was viewed as having a mixed personality disorder. In August 1992, the Division of Vocational Rehabilitation referred him for a psychiatric evaluation. He reported first having psychiatric contact in 1971 when he sought psychotherapy regarding his first divorce. Axis I diagnoses were voyeurism, frotteurism, alcohol dependence in remission, and rule out PTSD. According to an April 1994 assessment, Dr. S.C., a private physician, believed that the Veteran's diagnosis of antisocial personality disorder was incorrect. Instead, this physician believed the Veteran displayed behavior typical of Veterans with PTSD, including self-medication with alcohol. Dr. S.C. stated that part of Veteran's mental illness included pathologies which had their roots in the personality development stages, even though his personal history did not contain evidence of childhood or adolescent disorders. In May 1994, VA afforded the Veteran a VA compensation examination. He reported solitary confinement in a small enclosed box and periods of starvation during service. After examination and interview of him, the examiner felt that the Veteran's major complaint was indicative of a communication disorder, noting the Veteran's reports of having a tendency to isolate himself socially and having difficulty in expressing emotions. The examiner explained those manifestations seemed long-standing, even pre-military, and more consistent with the Veteran's character development rather than PTSD. Axis I diagnosis was frotteurism, voyeurism, and history of alcohol and marijuana dependence, in remission. The examiner noted further that the Veteran did not complain of symptoms of major depression and denied a history of psychotic symptoms. Although he reported becoming obsessed with thoughts, he denied any compulsive rituals. Thus, the examiner felt that the Veteran did not fulfill all of the criteria for a diagnosis of obsessive-compulsive disorder. It was further noted that, while he reported nightmares with themes of death, sometimes related to war, they were not of actual experiences that he himself had experienced. The examiner pointed out the Veteran did not report flashbacks, increased startle response, sleep disturbances, or other symptoms of PTSD, except for the social isolation and restrictive affect. The examiner believed that the Veteran likely had some developmental interpersonal difficulties prior to military service which then were greatly impacted upon through the stresses of military life. According to a June 1998 VA mental health intake note, the Veteran reported feeling depressed and feeling fatigued. His past psychiatric and medical history was noted. A July 1998 VA mental health psychiatry/psychology note shows diagnoses of dysthymia and mixed personal disorder. An August 1998 VA initial treatment plan note shows a diagnosis of depressive disorder. In October 2002, VA afforded the Veteran a VA general medical examination; pertinent diagnosis was depression. He was advised to see the psychiatrist for an evaluation. According to a Clinical Referral Data form dated in February 2003, the Veteran was referred to an inpatient PTSD program at a VA hospital. His principal diagnosis was an impulse-control disorder, not otherwise specified, and complicated PTSD. VA outpatient records dated in September 2003 show a PTSD diagnosis by a VA psychiatrist who listed the Veteran's symptoms as hyper-arousal, intrusive thoughts, re-experiencing of trauma, avoidance, and numbing of emotions. According to January 2005 VA progress notes, a psychiatrist reviewed the Veteran's reported stressors and the symptoms (a temper problem, anger, sleep disturbance, flashbacks, and making bomb threats) shown in the medical records; diagnosis was PTSD. In April 2007, the Veteran underwent an additional VA compensation examination. He reported that he flew over Vietnam in 1968 because the squadron he was relieving had been shot down and feared being shot down himself. He stated further that, during his second period of service, he caught the end of a cruise on an aircraft carrier and during that cruise, noting that two aircraft pilots were lost after their planes were launched. In terms of the interview, the VA examiner noted that the Veteran was a difficult historian to follow and gave very vague answers. The examiner observed the Veteran was unable to spontaneously relate any symptoms which would support a diagnosis of PTSD. Axis I diagnosis was deferred. The examiner stated there was nothing the Veteran reported during the interview and nothing in his claims file supporting a diagnosis of PTSD. The Veteran had an additional VA compensation examination in May 2007, at which time he declined psychological testing because, from his perspective, he had had a bad experience in the past. The examiner addressed one of the verified stressors, but did not render a diagnosis. Because the medical evidence conflicted as to whether the Veteran satisfied the DSM-IV criteria for a PTSD diagnosis, the Board requested an IME opinion that was provided in July 2009 by C.J.R, M.D., J.D., an Assistant Professor, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin. Ultimately, this medical expert concluded the Veteran does not meet the DSM-IV criteria for a diagnosis of PTSD. A VA mental health psychotherapy note dated in April 2011 shows Axis I diagnoses were dysthymia and PTSD. The clinical psychologist felt that the Veteran's mental disorder was related to the military but also noted that the Veteran had significant personality disorder traits that, at times, overshadowed his anxiety and PTSD symptoms over the years. During the course of this appeal, the Veteran has listed several stressors that he believes caused him to develop PTSD, and VA was able to verify two of them. The first confirmed stressor involves him witnessing plane crashes while serving aboard the USS Oriskany. The command history reports from this ship are of record, and confirm the crashes occurred while he was serving aboard this vessel. The second confirmed stressor occurred while he was attending Survival, Evasion, Resistance, and Escape ("SERE") training, where he was confined to a small box with poor ventilation for at least 25 minutes at a time. This stressor was verified by a letter that he sent to his grandmother while at "SERE" training, wherein he described what the training entailed. As shown, the Veteran has had a lengthy and complex psychiatric history. He has been diagnosed with numerous mental disorders - including passive-aggressive personality disorder, sexual deviation, paranoid schizophrenia, sociopathy, alcohol dependence, PTSD, mixed personality disorder, voyeurism, froetterism, history of alcoholism with mixed personality disorder with narcissistic, paranoid, and antisocial features, cannabis dependence, personality disorder not otherwise specified with periods of developmental interpersonal difficulties as a child, and dysthymia versus generalized anxiety disorder versus PTSD. But after a review of the evidence, the Board finds that the preponderance of the evidence of record is against a finding that he meets the DSM-IV criteria for PTSD. In arriving at the conclusion that the Veteran has PTSD, Dr. S.C. in 1994 relied on a number of stressors, only one of which was actually verified - the "SERE" stressor. Importantly, though, Dr. S.C. also relied on unsubstantiated statements from the Veteran - that his duty experiences were conducted under high risk of death while in a powerless position (e.g. flying with a pilot known to be suicidal or in an airplane from which no one had ever successfully parachuted). Additionally, the VA clinical psychologist in April 2011 diagnosed PTSD based on three stressors - being on a plane in service that ran out of fuel; experiencing an emergency drill while on a plane from the Philippines to Thailand during service; and being involved in "SERE" training. Similarly, only one of those stressors has been verified. Only one confirmed stressor is needed to support a PTSD diagnosis, but, here, there is no indication the "SERE" training alone caused symptoms sufficient to meet all of the criteria necessary for a PTSD diagnosis. On the other hand, the 2009 IME determination was based solely on the only two stressors that have been verified. The IME opinion that the Veteran does not have PTSD is partially based on the Veteran's lack of recollections, flashbacks, and intense duress or reactivity cues surrounding his purported stressors. This IME opinion also provides that the Veteran's symptoms do not include the avoidance of stimuli as might be associated with the asserted trauma in the case of PTSD. As well, the IME noted the Veteran has not reported increased startle response or hypervigilence. This IME opinion further indicates that the Veteran's history of anger outbursts and irritability is better accounted for by his history of antisocial tendencies and personality disorder as opposed to PTSD. In explaining the medical rationale of his unfavorable opinion, the IME provided a lengthy, comprehensive discussion of the relevant evidence - including talking extensively about the specific complaints the Veteran had made through the years dating back to his military service, and even his life prior to service, as well as the objective clinical findings of the several instances that he had been evaluated and treated. The adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if, as here, the expert fairly considered the material evidence seemingly supporting the Veteran's position. See Wray v. Brown, 7 Vet. App. 488, 493 (1995). Weighing the evidence that is currently of record, the Board finds the IME's opinion to be the most well-reasoned, as it is based on an objective analysis of the evidence available at the time and contains a comprehensive discussion of the medical rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). So the Board finds that the most probative (meaning competent and credible) medical and other evidence of record indicates the Veteran does not have the required DSM diagnosis of PTSD. The Board also sees that this IME finding is consistent with the previous determinations by the June 1990 psychologist, and VA opinions provided in May 1994, October 2002, and April 2007; these other doctors similarly did not render a PTSD diagnosis in consideration of the DSM-IV criteria, finding, instead, these criteria were not satisfied. The Veteran's failure to appear at the scheduled examination which was provided to him three times between 2012 and 2013 prevented further investigation and another opinion considering the additional VA treatment records that were physically added to the claims file after the IME opinion was provided. Therefore, in weighing the probative value of the competent and credible evidence currently of record, the Board finds he does not have the requisite current diagnosis of PTSD that is in accordance with VA regulation, namely, 38 C.F.R. § 4.125(a) that in turn refers the rater to the DSM-IV. Hence, there cannot possibly be any correlation between this, for all intents and purposes, nonexistent condition and his military service. Hickson v. West, 12 Vet. App. 247 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). The PTSD claim therefore must be denied. As mentioned, however, the record also contains medical evidence of other psychiatric disorders - in turn, according to the holding in Clemons, requiring that the Board also consider these other diagnoses. At the time the Veteran entered military service, there were no psychiatric problems or issues noted or observed during his enlistment physical, either in the way of a relevant subjective complaint, pertinent history, or objective clinical finding such as a noteworthy diagnosis. The Board therefore must presume that he entered service in sound mental health, with the possible exception of the personality disorder for the reasons already discussed. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The Board also finds that this presumption has not been rebutted, since clear and unmistakable evidence does not show that his psychiatric disorders since diagnosed pre-existed his military service. Indeed, the only probative medical evidence addressing this was the July 2009 IME opinion. In this regard, the IME determined that there is no clear and unmistakable evidence of a mental disorder prior to the Veteran's service in 1966, at which time he was 19 years old. The July 2009 IME opinion indicates the Veteran's diagnosis of personality disorder has been consistent since 1984, and that he by his own report as well as that of a private physician has had "anger problems" since 1984, so not beginning until some 10 years after his discharge from service in 1974. The IME also noted the Veteran's significant criminal history showing antisocial personality traits, explaining that an antisocial personality disorder requires a person to be at least 18 years old. When a person is less than 18 years old, the examiner explained that it would have likely shown itself through the presence of a conduct disorder. The Veteran by his own report and by observation has had anger problems for 37 years. Further, as noted by the IME, the Veteran's STRs are completely unremarkable for any relevant complaints of or treatment for psychiatric-related symptoms while in the military - including according to the reports of his entrance and separation examinations. Consequently, service records are notably absent of any instance of superimposed injury or disease that could have conceivably aggravated an existing personality disorder. See Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). See also VAOPGCPREC 82-90 (July 18, 1990). Moreover, the post-service psychiatric diagnoses are not shown to have been superimposed upon his personality disorder and in turn related to service. There is also no suggestion of a psychosis until August 1980 when he was admitted to Vermont State Hospital with a questionable diagnosis of schizophrenia. A psychosis therefore is not shown within the first post-service year, and certainly not to the required minimum compensable degree of at least 10-percent disabling. See again 38 C.F.R. § 3.384. See also 38 C.F.R. § 4.125-4.130, Diagnostic Codes (DCs) 9201-9211, pertaining to Schizophrenia and other psychotic disorders. The preponderance of the evidence is also against a finding that a mental disorder of any sort, irrespective of the specific diagnosis, is linked to his military service. The probative July 2009 IME opinion did not relate any current psychiatric disorder to the Veteran's military service. And although the April 2011 clinical psychologist's indicated the Veteran's anxiety is related to his military service, that opinion is of less probative value, as it too is based in part on unsubstantiated stressors reported by the Veteran. Again, findings from an additional VA examination could have helped to support this claim, but he did not report. Based on the foregoing, it can likewise be concluded there is no basis upon which to find that there is any general psychiatric condition apart from PTSD that would warrant granting service connection in the present case. The Veteran is competent to report observable symptoms, such as depressed or anxious feelings. However, the question of whether his current psychiatric disorder is related to his service is a complex medical question, not capable of mere lay observation. See Jandreau, 492 F.3d at 1376 (noting that lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 308-09 (2007) (finding that lay testimony is competent to establish the presence of varicose veins); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). In certain other instances, however, not involving just simple conditions, lay evidence has been found not competent to establish the required attribution of the symptoms to a particular diagnosis and to causally relate the underlying diagnosis to service. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine additionally whether the evidence also is credible). Only if evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("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) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Baldwin v. West, 13 Vet. App. 1, 8 (1999). 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. 38 C.F.R. § 3.159(a)(2). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Because, here, the record is unremarkable for any evidence suggesting the Veteran has the appropriate training, experience, or expertise to provide a medical opinion concerning the appropriate diagnosis or etiology of a psychiatric condition, he is not competent to ascribe specific symptoms to a specific diagnosis or to, in turn, causally relate the disorder to events coincident with his military service. Accordingly, the competent medical evidence outweighs his lay reports regarding diagnosis and etiology, and it is entirely permissible in this circumstance to give more credence to the medical evidence, including the IME opinion, over his lay testimony. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record."). Moreover, although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of the other factors. See Cartright, 2 Vet. App. at 25; accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). Additionally, the preponderance of the evidence shows the Veteran has not experienced continuous psychiatric symptoms since his service. His assertion of continuity of symptomatology since service, while competent, is not credible, and therefore not probative. As explained, a psychosis is a chronic condition listed in § 3.309(a) and therefore the showing of continuity of symptomatology since service is allowed to establish the required chronicity of disease or injury in service and linkage between current disability and service. However, as indicated, there is no evidence of a psychosis until 1980, which is approximately six years after service. This multi-year gap is not altogether determinative or dispositive of whether he had a psychosis during those intervening years dating back to his service, but it is nonetheless probative evidence tending to refute this notion. 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, just not the only or sole factor). See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology and had failed to account for the lengthy time period for which there was no clinical documentation of the claimed disorder). He has not shown continuity of symptomatology since his discharge from service as specifically concerning any psychosis. Moreover, although symptoms, not treatment for the symptoms, is the essence of continuity of symptomatology, and although establishing continuity of symptomatology under § 3.303(b) is an alternative method of showing chronicity of disease or injury in service to in turn link current disability to service, this notion is only applicable when the condition later complained about was noted in service. Clyburn v. West, 12 Vet. App. 296, 302 (1999); Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). And such was not the case here. The preponderance of the evidence, then, is against the Veteran's claim of entitlement to service connection for a mental disorder of any sort, so not just for PTSD but also for the several other conditions that have been diagnosed in the course of his evaluation and treatment - in turn meaning there is no reasonable doubt to resolve in his favor, and that his claim resultantly must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER Service connection for an acquired psychiatric disorder, inclusive of PTSD, is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs