Citation Nr: 1320849 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 01-02 481 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hemorrhoids. 2. Entitlement to service connection for essential hypertension, to include as secondary to hemorrhoids and diabetes mellitus, type II. 3. Entitlement to service connection for pulmonary hypertension, to include as secondary to hemorrhoids and diabetes mellitus, type II. 4. Entitlement to service connection for a psychiatric disorder, to include panic disorder or an anxiety disorder, to include as secondary to hemorrhoids. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from August 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of February 2000, March 2000 and February 2004 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In June 2005, the Veteran testified at a hearing before a Veterans Law Judge (VLJ) who has since left from the Board. A transcript of the hearing has been associated with the claims file. A Board decision in February 2006 denied service connection for sinusitis, hemorrhoids, essential and pulmonary hypertension, and a psychiatric disorder. The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a Memorandum Decision dated in December 2009, the Court vacated the Board's denial of those service connection claims and remanded the case for readjudication in accordance with the decision. In May 2010, the Board sent a letter to the Veteran informing him that the VLJ before whom he had testified in June 2005 had left and advised him that he had the right to a new hearing before another VLJ who would decide his case. See 38 U.S.C.A. § 7107(c) (West 2002) (providing that the member or members designated to conduct a hearing shall participate in making the final determination of a claim on appeal). In a June 2010 letter, the Veteran indicated that he did not desire an additional personal hearing before the Board. In September 2010, the issues of service connection for sinusitis, hemorrhoids, essential and pulmonary hypertension, and a psychiatric disorder were remanded to afford the Veteran VA examinations. VA examinations were provided in October 2010. A Board decision in February 2012 denied the issue of service connection for sinusitis and again remanded the issues of service connection for hemorrhoids, essential and pulmonary hypertension, and a psychiatric disorder to obtain an addendum opinion from the October 2010 examiner regarding the Veteran's hemorrhoids. The Board also remanded the issue of service connection for a heart disorder for the issuance of a statement of the case. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Since the last supplemental statement of the case (SSOC), additional evidence has been received, without a waiver, in the form of statements from the Veteran . Normally, absent a waiver from the Veteran, a remand is necessary when evidence is received by the Board that has not been considered by the RO. Disabled Am. Veterans v. Sec'y of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). Here, however, the statements, while pertinent to the issues, are merely cumulative or duplicative of information already in the claims file and therefore, considered by the RO. Consequently, a remand is not necessary. FINDINGS OF FACT 1. Hemorrhoids were not present during service and the currently diagnosed hemorrhoids did not develop as a result of any incident during service. 2. Essential hypertension was not present during service, was not manifest within a year of separation from service, and the currently diagnosed essential hypertension did not develop as a result of any incident during service. 3. Pulmonary hypertension was not present during service and the currently diagnosed pulmonary hypertension did not develop as a result of any incident during service. 4. A psychiatric disorder, to include panic disorder or an anxiety disorder, was not present during service, a psychosis was not manifest within a year of separation from service, and a currently diagnosed psychiatric disorder did not develop as a result of any incident during service. CONCLUSIONS OF LAW 1. Hemorrhoids were not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. Essential hypertension was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). 3. Pulmonary hypertension was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 4. A psychiatric disorder, to include panic disorder or an anxiety disorder, was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was notified in a letters dated in January 2000, March 2001 and July 2003 regarding the type of evidence necessary to establish his claims. He was instructed how to establish service connection. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. An April 2011 supplemental statement of the case notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs), post-service medical records and also secured examinations in furtherance of his claims. Pertinent VA examinations were obtained in October 2010 (all issues) and August 2012 (hemorrhoids). 38 C.F.R. § 3.159(c)(4). The VA examinations obtained in this case are sufficient, as the examiners conducted complete examinations, recorded all findings considered relevant under the applicable law and regulations, and offered well-supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. The Veteran was also provided with a hearing related to his present claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the VLJ explained the issues on appeal, but did not suggest the submission of any additional evidence. This was not necessary, however, because the Veteran fully described why he believed service connection was warranted for hemorrhoids, essential and pulmonary hypertension, and a psychiatric disorder. Accordingly, the Veteran is not shown to be prejudiced on this basis. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Pursuant to 38 C.F.R. § 3.303(b), when a chronic condition is present, a claimant may establish the second and third elements by demonstrating continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases (e.g., hypertension and psychoses) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). 1. Hemorrhoids The Veteran contends that in-service constipation caused his current hemorrhoids and that his hemorrhoids had their onset in service. See, e.g., June 2005 Hearing Transcript (T.) at 2-3. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that the Veteran's current hemorrhoids became manifest or otherwise originated during his period of service or are otherwise related to his military service. There is no finding that hemorrhoids were treated or diagnosed during service. The Veteran's pre-induction examination in June 1969 revealed clinically normal anus and rectum. In his June 1969 report of medical examination, he denied symptoms such as piles or rectal disease. No defects were noted in August 1969. His April 1971 separation examination revealed clinically normal anus and rectum. There is no indication in the Veteran's STRs that he incurred a specific event, injury or disease to his anus. There is also no indication that hemorrhoids had their onset in service. The Board acknowledges the Veteran's competent and credible testimony of suffering from constipation and rectal bleeding during service. See T. at 2-3. However, there is no indication in any of his STRs that he was treated for symptoms associated with any currently diagnosed hemorrhoids. There is also no indication of a diagnosis of hemorrhoids in his STRs. The Veteran's contemporaneous service records fail to show that the onset of hemorrhoids occurred during service. The totality of the evidence fails to show that the onset of any current hemorrhoids occurred during the Veteran's service. No medical professional has reported that the onset of any current hemorrhoids began during the Veteran's military service. The pertinent medical evidence that has been presented shows that the Veteran has been diagnosed with hemorrhoids since February 1972, less than one year after he was discharged from service. While his records continue to show hemorrhoids, the probative medical evidence of record does not indicate that the Veteran's hemorrhoids are related to his military service, to include being caused by his reported in-service constipation. At an October 2010 VA examination, the Veteran reported in-service rectal bleeding with problems since then. Following examination, the Veteran was diagnosed with internal and external hemorrhoids. The examiner opined that they could not resolve the issue of whether it was at least as likely as not that the Veteran's hemorrhoids were etiologically related to his military service without resorting to mere speculation. The examiner noted that the Veteran's STRs were silent for complaint of, diagnosis of, or treatment for hemorrhoids. The Veteran was noted to have external hemorrhoids incidentally noted on examination within 12 months of release from active duty. Private opinions from J.L., M.D. dated in May 2012 and June 2012 indicate that the Veteran's hemorrhoids were related to his military service. In May 2012, Dr. J.L. reported that he suspected that the chronic constipation that the Veteran developed in service probably contributed to the development of hemorrhoids with the associated straining involved and subsequent diminishment of anal sphincter control and prolapsed hemorrhoids over the years. Therefore, it was greater than 50 percent chance that that was related to the constipation acquired while serving in the military. The June 2012 treatment record shows that the Veteran reported symptoms of hemorrhoidal bleeding began in service. The combination of constipation and straining despite attempts at treatment probably had contributed to the worsening of his hemorrhoidal condition. The Veteran was afforded a second VA examination in August 2012. He reported that in 1971, he had constipation and developed hemorrhoids. He was never treated for constipation and hemorrhoids until after service. Following examination, he was diagnosed with internal or external hemorrhoids. The examiner opined that the Veteran's hemorrhoids were less likely as not due to service. There was no objective evidence to connect the Veteran's incidental finding of external hemorrhoids found post-service to his time in-service. His medical records were absolutely silent in regards to any complaint related to hemorrhoids. During separation examination, rectal examination was normal and there was no mention of any complaint/problem/disorder related to hemorrhoids. He reported a history of chronic constipation during service, to which he attributed the development of hemorrhoids. Review of medical literature showed that the development of symptomatic hemorrhoids had been associated with advancing age, diarrhea, pregnancy, pelvic tumors, prolonged sitting, straining and chronic constipation. The association with chronic constipation, however, was not supported in a large epidemiologic study. The cause of symptomatic internal hemorrhoids was not completely understood, but might be due to multiple factors: advancing age or aggravating conditions, causing deterioration of the connective tissue which anchored the hemorrhoids to the underlying sphincter mechanism; hypertrophy or increased tone of the internal anal sphincter; and/or swelling of the hemorrhoidal cushions. The Veteran's incidental finding of an external hemorrhoid in February 1971 could not be reasonably connected to active duty service when there was no objective evidence of any complaint or treatment during active duty and the separation examination noted a normal rectal examination. To determine the exact date/cause of the hemorrhoids would only be speculative at best. The probative medical evidence simply fails to adequately establish any nexus between any current hemorrhoids and the Veteran's military service. Although Dr. J.L. provided two opinions indicating that the Veteran's hemorrhoids are related to his military service, the Board finds that they have less probative weight than the August 2012 VA examiner's opinion. The August 2012 VA examiner cited to medical literature indicating that the association of hemorrhoids with chronic constipation was not supported in a large epidemiologic study. Although Dr. J.L. provided a rationale for his opinions, the Board finds that the VA examiner's opinion that took into account the pertinent medical literature, as well as a review of the Veteran's records, to include his separation examination showing normal anus and rectum, is more probative. Furthermore, to the extent that the Veteran's contentions indicate a continuity of hemorrhoidal symptomatology since service, the Board is cognizant of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) recent holding in Walker v. Shinseki, 708 F.3d 1331. In that decision, the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Hemorrhoids are not a chronic condition as per 38 C.F.R. § 3.309(a). Therefore, the Veteran's contentions regarding a continuity of symptomatology cannot support a finding of a nexus. In sum, the probative medical evidence of record shows that the Veteran's hemorrhoids are not related to his military service. Without competent evidence of an association between current hemorrhoids and his active duty, service connection for hemorrhoids is not warranted. Although as a lay person, the Veteran is competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of hemorrhoids falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4 (lay persons not competent to diagnose cancer). As such, his own assertions as to etiology have no probative value. Without evidence of the onset of hemorrhoids in service or competent evidence of an association between current hemorrhoids and the Veteran's active duty, service connection for hemorrhoids is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for hemorrhoids. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for hemorrhoids is denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2012). 2. Essential Hypertension The Veteran contends that he has essential hypertension that is related to his military service, to include being secondary to hemorrhoids and diabetes mellitus, type II. See, e.g., May 2003 claim. For the reasons set forth above, service connection for hemorrhoids is not warranted. As for the Veteran's contention that essential hypertension is secondary to diabetes mellitus, type II, the Board observes that in an April 2012 rating decision, the RO denied service connection for diabetes mellitus, type II. A statement of the case was issued in February 2013; the Veteran did not file a substantive appeal. Therefore, as service connection is not in effect for hemorrhoids or diabetes mellitus, type II, the Board will not address the Veteran's secondary service connection theories, but will review his claim on direct and presumptive bases. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that the Veteran's current essential hypertension became manifest or otherwise originated during his period of service, within one year of discharge from service or is otherwise related to his military service. There is no finding that essential hypertension was treated or diagnosed during service. The Veteran's pre-induction examination in June 1969 revealed clinically normal heart and vascular system. His blood pressure was 132/70. In his June 1969 report of medical examination, he denied symptoms such as high blood pressure. No defects were noted in August 1969. His April 1971 separation examination revealed clinically normal heart and vascular system. His blood pressure was 100/62. There is no indication in the Veteran's STRs that he incurred a specific event, injury or disease to his cardiovascular system. There is also no indication that essential hypertension had its onset in service. Indeed, the Veteran had not contended that he had essential hypertension in service. At his June 2005 hearing, he testified being diagnosed with hypertension in 1998. T. at 5. The Veteran's contemporaneous service records fail to show that the onset of essential hypertension occurred during service. The totality of the evidence fails to show that the onset of any current essential hypertension occurred during the Veteran's service. No medical professional has reported that the onset of any current essential hypertension began during the Veteran's military service. The pertinent medical evidence that has been presented shows that the Veteran has been diagnosed with essential hypertension since 1998. Records prior to that fail to show a diagnosis of hypertension. In this regard, the Board observes that the Veteran denied a history of hypertension in April 1984. In a June 1999 treatment record, the Veteran reported that his hypertension was diagnosed in 1998. A record in November 1999 confirmed that the Veteran had essential hypertension. None of the Veteran's treatment records contain any opinion relating essential hypertension to his military service. No medical professional has provided any opinion indicating that any diagnosed essential hypertension was manifest to a degree of 10 percent or more within one year from the Veteran's discharge from service. The only medical opinion of record, that of an October 2010 VA examiner, indicates that the Veteran's essential hypertension is not related to his military service. At the October 2010 VA examination, the Veteran reported that he was not told about hypertension until 1998. The examiner noted that the Veteran's medical record within two years of active duty was silent for hypertension. Following examination, he was diagnosed with essential hypertension. The examiner opined that it was not related to the Veteran's military service. The examiner noted that the Veteran's STRs were silent for hypertension. The opinion was based on medical literature review, medical record review and clinical experience. The pertinent medical evidence that has been presented shows a current diagnosis of essential hypertension; however, the evidence does not contain medical opinions relating any currently diagnosed essential hypertension to the Veteran's military service. Indeed, the Veteran has not contended that any medical professional has opined that his essential hypertension is related to his military service. The Veteran's contentions during this appeal do not indicate that he had hypertension in service or symptoms associated with hypertension in service. The probative medical evidence simply fails to adequately establish any nexus between any current essential hypertension and the Veteran's military service. As noted above, the earliest indication of essential hypertension is in 1998, more than two decades after the Veteran was discharged from service. No medical professional has provided any opinion indicating that the Veteran's essential hypertension is related to his military service. The only opinion of record is that of the October 2010 examiner, which is uncontradicted. Without competent evidence of an association between current essential hypertension and his active duty, service connection for essential hypertension is not warranted. Although as a lay person, the Veteran is competent to provide opinions on some medical issues, see Kahana at 435, as to the specific issue in this case, the etiology of essential hypertension falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. As such, his own assertions as to etiology have no probative value. Without evidence of the onset of essential hypertension in service or competent evidence of an association between current essential hypertension and the Veteran's active duty, service connection for essential hypertension is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for essential hypertension. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for essential hypertension is denied. See 38 U.S.C.A §5107. 3. Pulmonary Hypertension The Veteran contends that he has pulmonary hypertension that is related to his military service, to include being secondary to hemorrhoids and diabetes mellitus, type II. See, e.g., May 2003 claim. As with essential hypertension, the Board will not address the Veteran's secondary service connection theories, but will review his claim on a direct basis. As for service connection on a presumptive basis, the Board observes that hypertension is listed in 38 C.F.R. § 3.309(a) as a cardiovascular-renal disease. However, pulmonary hypertension is defined as increased pressure within the pulmonary arterial circulation. See Dorland's Illustrated Medical Dictionary, 909 (31st ed. 2007). Additionally, VA's rating criteria characterizes pulmonary hypertension as a nontuberculous respiratory disease. See 38 C.F.R. § 4.97, Diagnostic Code 6817 (2012). Therefore, as pulmonary hypertension is not indicated as a cardiovascular-renal disease, the Board finds that presumptive service connection is not for application. As such, the Board will only adjudicate the Veteran's claim on a direct basis. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that the Veteran's current pulmonary hypertension became manifest or otherwise originated during his period of service or is otherwise related to his military service. There is no finding that pulmonary hypertension was treated or diagnosed during service. The Veteran's pre-induction examination in June 1969 revealed clinically normal heart, lungs and chest. In his June 1969 report of medical examination, he denied all symptoms listed on the report. No defects were noted in August 1969. His April 1971 separation examination revealed clinically normal heart, lungs and chest. There is no indication in the Veteran's STRs that he incurred a specific event, injury or disease to his respiratory system. There is also no indication that pulmonary hypertension had its onset in service. Indeed, the Veteran had not contended that he had pulmonary hypertension in service. The Veteran's contemporaneous service records fail to show that the onset of pulmonary hypertension occurred during service. The totality of the evidence fails to show that the onset of any current pulmonary hypertension occurred during the Veteran's service. No medical professional has reported that the onset of any current pulmonary hypertension began during the Veteran's military service. The pertinent medical evidence that has been presented shows that the Veteran has been diagnosed with pulmonary hypertension since January 2003. None of the Veteran's treatment records contain any opinion relating pulmonary hypertension to his military service. The only medical opinion of record, that of an October 2010 VA examiner, indicates that the Veteran's pulmonary hypertension is not related to his military service. At the October 2010 VA examination, the Veteran reported that his pulmonary hypertension occurred in 2003 when his mitral valve problem started getting worse. He was advised that blood was backing up in his heart and that was causing pressure in the arteries. It was confirmed on cardiac catheterization. Following examination, he was diagnosed with pulmonary hypertension. The examiner opined that it was not related to the Veteran's military service. The examiner noted that the Veteran's STRs and medical record within 18 months of active duty were silent for pulmonary hypertension. The opinion was based on medical literature review, medical record review and clinical experience. The pertinent medical evidence that has been presented shows a current diagnosis of pulmonary hypertension; however, the evidence does not contain medical opinions relating any currently diagnosed pulmonary hypertension to the Veteran's military service. Indeed, the Veteran has not contended that any medical professional has opined that his pulmonary hypertension is related to his military service. The Veteran's contentions during this appeal do not indicate that he had pulmonary hypertension in service. The probative medical evidence simply fails to adequately establish any nexus between any current pulmonary hypertension and the Veteran's military service. As noted above, the earliest indication of essential hypertension is in 2003, more than three decades after the Veteran was discharged from service. No medical professional has provided any opinion indicating that the Veteran's pulmonary hypertension is related to his military service. The only opinion of record is that of the October 2010 examiner, which is uncontradicted. Without competent evidence of an association between current pulmonary hypertension and his active duty, service connection for pulmonary hypertension is not warranted. Although as a lay person, the Veteran is competent to provide opinions on some medical issues, see Kahana at 435, as to the specific issue in this case, the etiology of pulmonary hypertension falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. As such, his own assertions as to etiology have no probative value. Without evidence of the onset of pulmonary hypertension in service or competent evidence of an association between current pulmonary hypertension and the Veteran's active duty, service connection for pulmonary hypertension is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for pulmonary hypertension. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for pulmonary hypertension is denied. See 38 U.S.C.A §5107. 4. Psychiatric Disorder The Veteran contends that he has a psychiatric disorder, to include panic disorder or an anxiety disorder, that is related to his military service, to include being secondary to hemorrhoids. See, e.g., T. at 7-8. As with essential and pulmonary hypertension, the Board will not address the Veteran's secondary service connection theory, but will review his claim on direct and presumptive bases. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that any current psychiatric disorder became manifest or otherwise originated during his period of service, within one year of discharge from service or is otherwise related to his military service. There is no finding that a psychiatric disorder was treated or diagnosed during service. The Veteran's pre-induction examination in June 1969 revealed a clinically normal psychiatric system. In his June 1969 report of medical examination, he denied symptoms such as frequent trouble sleeping; frequent or terrifying nightmares; depression or excessive worry; and nervous trouble of any sort. No defects were noted in August 1969. His April 1971 separation examination revealed a clinically normal psychiatric system. There is no indication in the Veteran's STRs that he incurred a specific event, injury or disease to his psychiatric system. There is also no indication that a psychiatric disorder had its onset in service. Indeed, the Veteran had not contended that he had a psychiatric disorder in service. At his June 2005 hearing, he testified that his panic disorder was related to gastrointestinal bleeding and hemorrhoids in 1984. T. at 7-8. The Veteran's contemporaneous service records fail to show that the onset of a psychiatric disorder occurred during service. The totality of the evidence fails to show that the onset of any current psychiatric disorder occurred during the Veteran's service. No medical professional has reported that the onset of any current psychiatric disorder began during the Veteran's military service. The pertinent medical evidence that has been presented shows that the Veteran has been diagnosed with various psychiatric disorders since 1986. A treatment record dated in September 1986 showed a diagnosis of situational anxiety. At a November 1987 VA examination, the Veteran reported that the most traumatic thing that happened to him in Vietnam was the "constant aggravation day after day." He was unable to determine any specific reasons in his life as to why he would be so anxious, but claimed "until I went to the war I was never like this." Other than that, he was unable to give any specific events that happened in the war that would cause the present symptomatology. He was diagnosed with chronic anxiety neurosis; no opinion as to the etiology was provided. The Veteran was afforded a VA examination in August 2003. He reported being under enemy fire in some incidents when participating in eight or nine missions when patrolling off shore of Vietnam. The Veteran was diagnosed with adjustment disorder with depressed mood. The examiner opined that the precipitating factor was his heart condition and a recent surgery. At an October 2010 VA examination, the Veteran attributed depression to episodes of heart palpitation and a side effect of medication; anxiety coincided with the depression. Following examination, the Veteran was diagnosed with adjustment disorder, mixed with anxiety and depression mood. The examiner reported that they would have to resort to mere speculation to provide an opinion as to whether the Veteran's psychiatric disorder was related to his military service. The examiner explained that test results reflected that the Veteran was over endorsing psychological symptoms. Also, his description of depression was inconsistent with records. Therefore, the examiner could not discern legitimate symptoms from feigned/exaggerated symptoms. The examiner's opinion was based on a review of the Veteran's claims file and interview with the Veteran. The pertinent medical evidence that has been presented shows a current diagnosis of adjustment disorder; however, the evidence does not contain medical opinions relating any currently diagnosed adjustment disorder, or any other psychiatric disorder, to the Veteran's military service. Indeed, the Veteran has not contended that any medical professional has opined that he has a psychiatric disorder related to his military service. The only medical opinion of record, that of the October 2010 examiner, indicates that an opinion regarding whether the Veteran's psychiatric disorder is related to his military service could not be answered without resort to mere speculation. This is an adequate opinion as the examiner provided an explanation as to why they could not provide an opinion regarding the etiology of the Veteran's psychiatric disorder. See Jones v. Shinseki, 23 Vet. App. 382 (2010). Additionally, no medical professional has provided any opinion indicating that the Veteran has a psychosis that manifest to a degree of 10 percent or more within one year from the Veteran's discharge from service; the Veteran has not been diagnosed with a psychosis during this appeal. The probative medical evidence simply fails to adequately establish any nexus between any current psychiatric disorder and the Veteran's military service. As noted above, the earliest indication of a psychiatric disorder is in 1986, more than one decade after the Veteran was discharged from service. No medical professional has provided any opinion indicating that the Veteran has a psychiatric disorder related to his military service. Without competent evidence of an association between a current psychiatric disorder his active duty, service connection for a psychiatric disorder, to include panic disorder or anxiety disorder, is not warranted. Although as a lay person, the Veteran is competent to provide opinions on some medical issues, see Kahana at 435, as to the specific issue in this case, the etiology of a psychiatric disorder, to include panic disorder or anxiety disorder, falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. As such, his own assertions as to etiology have no probative value. Without evidence of the onset of a psychiatric disorder, to include panic disorder or anxiety disorder, in service or competent evidence of an association between a current psychiatric disorder, to include panic disorder or anxiety disorder, and the Veteran's active duty, service connection for a psychiatric disorder, to include panic disorder or anxiety disorder, is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a psychiatric disorder, to include panic disorder or anxiety disorder. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a psychiatric disorder, to include panic disorder or anxiety disorder, is denied. See 38 U.S.C.A §5107. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for essential hypertension, to include as secondary to hemorrhoids and diabetes mellitus, type II is denied. Entitlement to service connection for pulmonary hypertension, to include as secondary to hemorrhoids and diabetes mellitus, type II is denied. Entitlement to service connection for a psychiatric disorder, to include panic disorder or an anxiety disorder, to include as secondary to hemorrhoids is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs