Citation Nr: 1322485 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 07-28 106 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for Type II diabetes mellitus. 2. Entitlement to service connection for a chronic acquired psychiatric disorder, to include major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder, and post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran's service personnel records show that he served on active duty from October 1979 to January 1980. The military records also show that he served a second period of active duty from May 2002 to November 2002 and thereafter a third and final period of active duty from February 2003 to August 2003. Additionally, he served on periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA) in the National Guard. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision by the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA) which, inter alia, denied the Veteran's claims of entitlement to service connection for Type II diabetes mellitus and a chronic acquired psychiatric disorder (to include major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder, and PTSD). During the course of the appeal, in June 2011, the Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for additional evidentiary development. Following this development, the denials of VA compensation for Type II diabetes mellitus and a chronic psychiatric disorder were confirmed in a June 2012 rating decision/supplemental statement of the case. The case was thereafter returned to the Board in July 2012 and the Veteran now continues his appeal. FINDINGS OF FACT 1. The objective clinical evidence does not establish onset of Type II diabetes mellitus during any period of active military service, or a definitive link between Type II diabetes and a specific event occurring during documented periods of ACDUTRA or INACDUTRA. 2. A preponderance of the evidence fails to establish a diagnosis of PTSD at any time during the appeal period. 3. The objective clinical evidence does not establish onset of a chronic acquired psychiatric disorder (to include major depressive disorder, depressive disorder not otherwise specified, and dysthymic disorder) during any period of active military service, or a definitive link between any chronic psychiatric diagnosis made during the pendency of the claim and a specific event occurring during documented periods of ACDUTRA or INACDUTRA. CONCLUSIONS OF LAW 1. Type II diabetes mellitus was not incurred during any of the Veteran's periods of active duty or ACDUTRA, nor is it presumed to have been incurred during any of the Veteran's periods of active duty. 38 U.S.C.A. §§ 101(22), (24)(B) 1110, 1111, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Type II diabetes mellitus is not a physical injury, nor is it due to a physical injury or an acute myocardial infarction that was incurred during INACDUTRA. 38 U.S.C.A. § 101(23), 24(C) (West 2002); 38 C.F.R. § 3.303 (2012). 3. A chronic acquired psychiatric disorder (to include major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder, and PTSD)) was not incurred during any of the Veteran's periods of active duty or ACDUTRA, nor is major depressive disorder as a psychosis presumed to have been incurred during any of the Veteran's periods of active duty. 38 U.S.C.A. §§ 101(22), (24)(B), 1110, 1111, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 4. A chronic acquired psychiatric disorder is not a physical injury, nor is it due to a physical injury or an acute myocardial infarction that was incurred during INACDUTRA. 38 U.S.C.A. § 101(23), 24(C) (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) and VA's duty to assist. With respect to the service connection claim on appeal, the Board notes at the outset that, in accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Generally, the notice requirements of a claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b) (2012); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). The service connection claims on appeal were filed in April 2006. A VCAA notice letter was dispatched to the Veteran in May 2006, prior to the September 2006 rating decision now on appeal. The letter addresses the service connection issues on appeal and satisfies the above-described mandates, as well as the requirements that the Veteran be informed of how VA calculates degree of disability and assigns an effective date for the disability, as prescribed in Dingess v. Nicholson, 19 Vet. App. 473 (2006). There is no timing of notice error as fully compliant notice preceded the initial adjudication of the Veteran's claim. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. The Veteran's service treatment records for all three periods of active duty, his National Guard personnel and medical records, and post-service private and VA clinical records pertinent to the period from 2002 to 2012 have been obtained and associated with the claims file. These include private medical records pertaining to his diagnosis and treatment for diabetes and a chronic psychiatric disorder. The Board has also reviewed the Veteran's claims file as it appears on the Virtual VA electronic information database for any additional pertinent medical records. Those medical records obtained by VA that were initially received in Spanish have all been professionally translated into English and the translations have been associated with the claims file. With respect to the psychiatric disability claim on appeal, the Veteran has been provided with a VA medical examination in August 2011, in which an Axis I psychiatric diagnosis and a nexus opinion addressing the diagnosis' relationship with his periods of active service were obtained. The August 2011 evaluation report reflects that a VA psychiatrist examined the Veteran; that the psychiatrist reviewed the Veteran's claims file in conjunction with her examination; and that the psychiatrist's medical conclusions are predicated on her review of the claimant's pertinent clinical history. Therefore, the August 2011 examination is considered to be adequate for purposes of adjudicating the claim of entitlement to VA compensation for a chronic psychiatric disorder. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was not provided with a VA examination addressing the claim for service connection for Type II diabetes mellitus. However, this deficit does not render the existing record unusable for purposes of adjudicating this issue on the merits. The Board is mindful of the test prescribed by the United States Court of Appeals for Veterans Claims (Court) in McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), regarding whether a medical examination is necessary to adjudicate a claim, and finds that the absence of an examination addressing the diabetes mellitus issue is not prejudicial to the Veteran's claim as he has not met the criteria under McLendon to warrant such an examination and, furthermore, the National Guard and post-service VA and private medical records presently associated with the claims file provide sufficient evidence to decide this claim. A VA examination is therefore not necessary to adjudicate the matter. Specifically, the Board finds that the Veteran has not met all four elements set forth in McLendon, which emphasize that a VA examination must be provided when there is: (1) competent evidence of current disability or recurrent symptoms; (2) establishment of an in-service event, injury, or disease; (3) an indication that the current disability may be associated with the in-service event; and (4) insufficient competent medical evidence to decide the claim. As will be further discussed below, the Board has determined that the competent and credible evidence does not establish an in-service event, injury, or disease relating his current Type II diabetes mellitus diagnosis to any of his periods of active service. The second and third elements of the McLendon test have not been met. Therefore, the absence of a clinical examination addressing the diabetes claim does not constitute a breach of VA's duty to assist. The Board remand of June 2011 was to ensure that a thorough effort was undertaken by VA to verify all of the Veteran's periods of active service (including ACDUTRA and INACDUTRA), to obtain all available medical records relating to the Veteran's post-service psychiatric treatment and treatment for diabetes, and to schedule him for a VA psychiatric examination to verify his Axis I diagnoses and obtain a nexus opinion. The effort in this regard resulted in the inclusion of the aforementioned private and VA medical records for the period from 2002 - 2012 and the Veteran's National Guard service personnel records, which confirm that he served on three distinct periods of full-time active duty in 1979 - 1980, 2002, and 2003. As previously discussed, the VA psychiatric examination and nexus opinion requested on remand were obtained in August 2011. The Board finds that the RO/AMC has substantially complied with its instructions regarding the evidentiary development ordered by the Board in its remand of June 2011. Therefore, no additional remand for corrective action is required. [See Stegall v. West, 11 Vet. App. 268 (1998): A remand by the Board confers on a veteran or other claimant the right to VA compliance with the remand order and imposes on the Secretary a concomitant duty to ensure compliance with the terms of such an order. See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999): Exact compliance with the directives of a Board remand are not necessarily required if the purpose of the remand has been met, such that the RO's post-remand development is in substantial compliance with the Board's remand instructions.] Furthermore, the Board concludes as a factual matter that the existing clinical evidence of record is sufficient to decide the claim for VA compensation for diabetes, such that remanding the case for an examination to address this matter would be an unnecessary expenditure of VA resources. The Veteran was provided with adequate opportunity to submit or otherwise identify relevant evidence in support of his claims for service connection for Type II diabetes mellitus and a chronic psychiatric disorder. The Board finds that the record does not need any further development, nor does it need to be held open for submission by the Veteran of any additional evidence, and that no further delay in the adjudication of this appeal is warranted. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of his claims for service connection for diabetes and a chronic psychiatric disorder decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection laws and regulations. In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). With chronic disability or disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307 (2012)) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of abnormal sugar levels in urine, record of psychiatric counseling, or notation of psychiatric symptoms or complaints during service will respectively permit service connection for Type II diabetes mellitus or a chronic acquired psychiatric disorder, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a), (b) (2012). In this regard, the Veteran is presently service connected only for hypertension, which is rated 10 percent disabling. The Board has reviewed the evidence and notes that the Veteran does not contend, nor does the objective medical record indicate that his diabetes or diagnosed psychiatric disabilities are causally or etiologically linked to his hypertension, or are otherwise aggravated (which is to say permanently worsened beyond their natural progression) by his hypertension. As such, the Board finds no such secondary nexus is demonstrated and no further consideration of service connection for diabetes and/or a chronic psychiatric disability on the theory of proximate causation is warranted. For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes mellitus and psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-98; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), in which the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the theory of continuity of symptomatology can be used only in cases involving those diseases and conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). The records establish that the Veteran served on multiple periods of ACDUTRA and INACDUTRA as a member of the National Guard between June 1979 and August 2003. The records also show that he extended his enlistment in the National Guard in October 2006, although no additional periods of ACDUTRA or INACDUTRA are indicated beyond August 2003. As pertinent to the facts specific to the Veteran's individual case, active service is defined as any period of active duty (38 U.S.C.A. § 101(24)(A)); ACDUTRA during which disability or death was the result of a disease or injury incurred or aggravated in the line of duty (38 U.S.C.A. § 101(24)(B)); and any period of INACDUTRA during which disability or death was the result of an injury incurred or aggravated in the line of duty; or from an acute myocardial infarction, a cardiac arrest, or cerebrovascular accident occurring during such training (38 U.S.C.A. § 101(24)(C)). (a.) Entitlement to service connection for Type II diabetes mellitus. The medical evidence shows that the Veteran's earliest recorded clinical indication of onset of diabetes was presented in VA treatment note dated in mid-November 2004, which shows that he had glycosuria (elevated sugar in urine) that was objectively demonstrated on urinalysis conducted on this date. Thereafter, as of February 2005, the medical records reflect a diagnosis of, and treatment for Type II diabetes mellitus from that time forward. His active duty medical records do not present a diagnosis of diabetes or otherwise show any abnormal urinalysis findings indicating elevated sugar in his urine during active service. The clinical evidence from his National Guard service also does not indicate that the actual onset of the Veteran's diabetes coincided with any period of ACDUTRA or INACDUTRA. The Board notes that the notation of glycosuria in November 2004, which is the earliest indication of diabetes in the Veteran, was presented well over a year following his separation from his final period of active duty in August 2003. As such, his diabetes is not presumed to have been incurred during this last period of active military service. 38 C.F.R. §§ 3.307, 3.309. The evidence also fails to demonstrate onset of the Veteran's Type II diabetes mellitus during any of his established periods of active duty or ACDUTRA, or otherwise demonstrates that his diabetes represents a physical injury, or is due to a physical injury or acute myocardial infarction during INACDUTRA. As such, the Veteran's claim of service connection for Type II diabetes mellitus on the basis of his active service, ACDUTRA service, or INACDUTRA service must be denied. To the extent that the Veteran attempts to relate his Type II diabetes mellitus to his periods of active service, ACDUTRA, and INACDUTRA, based on his own personal knowledge of medicine and his familiarity with his individual medical history, the Board first notes that he is not shown in the record to be a trained medical clinician. He served as an infantryman in the National Guard, his medical records reflect that his vocational background is in construction and furniture upholstering, and that during an August 2011 VA psychiatric examination he reported that he worked fulltime as a city government employee. Although lay persons may be competent to provide opinions as to some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), as the specific question in this case regarding the actual time of onset of his diabetes falls outside the realm of common knowledge of a lay person, he lacks the competence to provide a probative medical opinion linking this disease to service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay persons are not competent to diagnose internal diseases of the endocrine system, such as diabetes mellitus). Type II diabetes mellitus is a disease whose diagnosis can only be objectively demonstrated through specific laboratory tests (urinalysis and blood testing) and examination by a trained physician or medical specialist such as an endocrinologist. In view of the foregoing discussion, the Board must deny the Veteran's appeal for service connection for Type II diabetes mellitus as the preponderance of the evidence is against allowing his claim. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED NEXT PAGE) (b.) Entitlement to service connection for a chronic acquired psychiatric disorder, to include major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder, and PTSD. In addition to the foregoing laws and regulations pertaining to service connection, service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with the American Psychiatric Association 's Diagnostic and Statistical Manual of Medical Disorders (4th ed. 1994) (DSM- IV), (2) credible supporting evidence that the claimed in-service stressors actually occurred, and (3) a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor(s). The clinical evidence shows that no diagnosis of, or treatment for complaints relating to a chronic acquired psychiatric disorder is presented in the Veteran's medical records from all three periods of active duty and his ACDUTRA/INACDUTRA in the National Guard. Although the medical history questionnaire associated with his July 2003 separation examination from his third and final period of active service reflects a reported history of depression and excessive worry, he was diagnosed as psychiatrically normal on the accompanying clinical evaluation. Furthermore, a post-deployment medical assessment dated in September 2003 shows a negative history of psychiatric symptoms or complaints. Post-service VA treatment notes reflect that the Veteran was psychiatrically evaluated for symptoms of depression for the first time in mid-November 2005, over two years following his separation from his final period of active duty in August 2003. Thereafter, the earliest clinical notation of an Axis I psychiatric diagnosis presented in the record is a January 2006 VA treatment note showing a diagnosis of depressive disorder not otherwise specified. Subsequent private and VA medical records dated 2006 - 2011 present Axis I psychiatric diagnoses that include major depressive disorder, depressive disorder not otherwise specified, and dysthymic disorder. PTSD was also presented in a November 2005 VA medical problem list, although no definitive PTSD diagnosis was presented. The Veteran's personnel records reflect that he was deployed to a combat zone in Kuwait from April - May 2003 and that he was awarded the Global War on Terror Medal. These records and written statements presented by the Veteran and his fellow servicemen who reportedly served alongside him indicate that he was assigned to an activated Army National Guard infantry unit tasked with augmenting harbor and littoral waterway security for naval and commercial vessels operating in the Persian Gulf that were delivering military supplies at Kuwaiti harbor facilities in support of the Iraq War. Although the objective historical documents do not indicate that he was exposed to actual combat, the statements of the Veteran and his fellow servicemen as lay witnesses indicate that they encountered and militarily engaged suspicious vessels manned by indigenous crews, whom they suspected may have been pirates. He contends that this was a stressor during active duty that resulted in PTSD. To obtain a conclusive Axis I diagnosis, the Veteran was examined by a VA psychiatrist in August 2011. After reviewing the Veteran's claims file, contemplating the multiple Axis I diagnoses presented, and interviewing the Veteran, the examining clinician determined that the Veteran's definitive psychiatric diagnosis was depressive disorder not otherwise specified. The VA psychiatrist recognized that the Veteran was exposed to a military stressor while providing harbor security during active duty in 2003 that met the criteria for fear of hostile military or terrorist activity that would be adequate to support a diagnosis of PTSD. However, notwithstanding this stressor, the clinician's opinion was that the Veteran did not meet the criteria for an Axis I diagnosis of PTSD and expressly ruled it out. The VA psychiatrist's opinion was also that the Veteran's depressive disorder not otherwise specified was not related to his active duty military service or service in the National Guard based on the following stated rationale: [T]here is no evidence of psychiatric complaints, psychiatric findings, [or] psychiatric treatment prior to [or during] the [Veteran's active] military service. [T]here is no evidence of psychiatric complaints, psychiatric findings, [or] psychiatric treatment within one year after discharge from the [final period of] military service [in August 2003]. [The] veteran sought psychiatric care in 2005, two years after his military discharge. [A] temporal relationship between the depressive disorder and the veteran's military service is not established. [Although the] veteran meets the DSM IV stressor criteria for PTSD; nonetheless, he does not fulfill the symptom criteria for persistent[ly] re-experiencing the traumatic event, the symptom criteria for persistent. . . avoidance of the stimulus, nor the stressor criteria for persistent hyper arousal. [I]n his evaluations at [a private] Mental Health Clinic [the Veteran] failed to establish a relationship between his military service and his neuropsychiatric condition. His main concerns [presented] were his financial problems and the abandonment of his first wife. The Veteran claims activities that involve hostile military activity, namely being fearful of enemy/pirate attack while providing security for naval and commercial vessels. New regulations set forth under 38 C.F.R. § 3.304(f)(3) affect the current question regarding the Veteran's claimed stressors. In view of the nature of the Veteran's service and supporting statement, the Board finds that the Veteran's claimed stressors are consistent with the circumstances of his service. However, notwithstanding the Veteran's in-service exposure to a stressor that was deemed to be sufficient to support a PTSD diagnosis, the psychiatrist who examined him in August 2011 expressly ruled out a diagnosis of PTSD as the Veteran's constellation of psychiatric symptoms did not meet the established criteria for PTSD. There is no competent opinion to the contrary. The Veteran's personal opinion/statement that he suffers from PTSD does not meet this threshold. He is not shown to hold the requisite training/education to diagnosis psychiatric disorders. He is clearly competent to endorse certain psychiatric symptoms and complaints. However, diagnosing PTSD requires specific clinical tests and examination by a trained mental health specialist such as a mental health counselor, clinical psychologist, or psychiatrist. Indeed, establishing service connection for PTSD under § 3.304(f)(3) requires that the diagnosis be made as part of a VA examination, which in this case was negative. The objective clinical evidence discussed above also fails to demonstrate onset of a chronic Axis I psychiatric disorder during any of his established periods of active duty or ACDUTRA. Furthermore, after considering and reconciling all the disparate Axis I diagnoses presented in the record up to August 2011, the psychiatrist determined that the Veteran's chronic psychiatric disorder is definitively diagnosed as a depressive disorder not otherwise specified, which had its onset no earlier than two years after his separation in August 2003 from his final period of active duty, is unrelated to any of his prior periods of military service (to include active duty, ACDUTRA, and INACDUTRA), and was apparently associated with his post-service concerns regarding his personal finances and his relationship with his first spouse. As such, the Veteran's claim of entitlement to service connection for a chronic acquired psychiatric disorder on the basis of his active service, ACDUTRA service, or INACDUTRA service must be denied. To the extent that the Veteran attempts to relate his Axis I diagnoses to his periods of active service, ACDUTRA, and INACDUTRA, based on his own personal knowledge of his individual history, the Board first notes that he is not shown in the record to be a trained psychologist or mental health counselor. As previously noted, he served as an infantryman in the National Guard, his medical records reflect that his vocational background is in construction and furniture upholstering, and during an August 2011 VA psychiatric examination he reported that he worked fulltime as a city government employee. Although lay persons may be competent to provide opinions as to some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), as the specific question in this case regarding his actual Axis I diagnosis and its time of onset relative to his periods of active service, ACDUTRA, and INACDUTRA falls outside the realm of common knowledge of a lay person, he lacks the competence to provide a probative clinical opinion linking his psychiatric diagnoses to his military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay persons are not competent to make Axis I diagnoses of chronic psychiatric disorder). Although the Veteran may be competent to report his perceived emotional and mental state for any given period, an Axis I psychiatric diagnosis can only be objectively demonstrated through specific clinical tests and examination by a trained mental health specialist such as a mental health counselor, clinical psychologist, or psychiatrist. In view of the foregoing discussion, the Board must deny the Veteran's appeal for service connection for a chronic acquired psychiatric disorder (to include major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder, and PTSD) as the preponderance of the evidence is against allowing his claim. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for Type II diabetes mellitus is denied. Service connection for a chronic acquired psychiatric disorder (to include major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder, and PTSD) is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs