Citation Nr: 1323315 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 05-26 990 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran had active service from May 1964 to August 1967 with service in Korea from May 1965 to June 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a decision of August 2004 by the Department of Veterans Affairs (VA) Nashville, Tennessee, Regional Office (RO). The Board previously remanded the Veteran's claim in March 2008, January 2011 and November 2012. The RO originally framed the issue on appeal as entitlement to service connection for PTSD; however, the record indicates that the Veteran has also been diagnosed with other psychiatric disorders to include recurrent Major Depression, psychotic depression, and depression. Claims for service connection for one psychiatric disability encompass claims based all other psychiatric diagnoses reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Veteran's claim is most appropriately characterized as reflected on the title page of this decision. The Veteran raised the issue of knee injuries while serving in the National Guard. See statement dated in October 2012. He may also have intended to raise other issues in that statement. Since these matters have not been the subject of a rating decision, they are referred to the RO for any appropriate consideration which may include clarification of the issues claimed. Also, in a May 2013 rating decision, the RO denied a claim of service connection for a thyroid gland condition. The Veteran was provided notice of that decision in May 2013 correspondence. The correspondence indicated that the Veteran's claim was decided based on a special initiative to complete the pending claim; that it was a provisional decision based on the evidence currently of record; and, if the Veteran had additional evidence to submit relative to his claim, he should submit such evidence to the RO within one year of the date of the notice letter. Meanwhile, the Board received, in March 2013 and April 2013, the Veteran's signed authorization to obtain medical records pertinent to his claim of service connection for a thyroid condition. The matter is therefore referred to the RO for appropriate action. FINDINGS OF FACT 1. The Veteran did not clearly and unmistakably have a psychiatric disorder prior to service. 2. The most probative medical evidence of record indicates that the Veteran does not have a diagnosis of PTSD related to an in-service stressor. 3. The Veteran's psychiatric disorder, variously diagnosed to include adjustment disorder with anxiety and major depressive disorder were first diagnosed many years after separation from service and are less likely than not related to any incident in service. CONCLUSION OF LAW 1. A psychiatric disorder, including PTSD, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.301, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by letter dated March 2004. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a service connection claim for PTSD, and the relative duties of VA and the claimant to obtain evidence. Subsequent letters sent to the Veteran in April 2008, February 2009, March 2010, June 2010, and July 2010 provided additional notice with regard to stressor information, the scheduling of examinations, and keeping the Veteran apprised of what was being done to assist with the development of his claim. The April 2008 letter specifically notified the Veteran of how initial disability ratings and effective dates are assigned for all grants of service connection, pursuant to the holding in Dingess. The Veteran responded with vague statements as to various stressors. The RO requested additional records with regard to the Veteran's National Guard duty, and attempted to corroborate the Veteran's stressors. Service treatment and personnel records pertaining to National Guard duty were obtained. With regard to VA's duty to assist, the RO has scheduled the Veteran for several VA examinations in conjunction with his claim. Pursuant to remand directives in January 2011 and November 2012, additional VA examinations were scheduled to address all outstanding issues with respect to this claim and to reconcile the differing opinions between prior examiners. The Veteran appeared for all of the examinations, the most recent of which took place in February 2013. The February 2013 examination is adequate, as it is based on a complete review of the record, including the Veteran's statements, a complete self-reported history and a physical examination. The examiner's opinion relies on sound medical principles, as well as an extensive chronological history of psychiatric findings during service and since service, all of which is noted in detail below. Thus, the VA examiner's opinion in February 2013 is adequate and highly probative. In light of the notices sent to the appellant, as discussed above, the duty to notify has been met. In addition, the agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). As noted above, VA has obtained service treatment and personnel records. VA has assisted the Veteran in obtaining evidence, afforded the Veteran physical examinations, obtained medical opinions as to the likely etiology of any diagnosed psychiatric disorder and/or whether any psychiatric disorder pre-existed service, had its onset during service or is otherwise related thereto. The Veteran was afforded an opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. Finally, it appears from the record that the Veteran's original claims file was lost at some point during the appeal, and his file has since been reconstructed. The Veteran was provided notice of this in August 2012 correspondence. Nonetheless, the current record contains documents that were of record when the claims folder was lost. Moreover, there is no evidence to which the Veteran points that is not in the claims file or the Virtual VA File. Pursuant to the most recent remand directives, the Veteran was asked to submit written authorization to obtain private treatment records, or to submit the records himself, and he has not responded to those requests. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. II. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Continuous service for 90 days or more during a period of war, or peace time service after December 31, 1946, and post-service development of a presumptive (chronic) disease such as psychosis to a degree of 10 percent within one year from the date of termination of such service, establishes a rebuttable presumption that the disease was incurred in service, even though there is no evidence of psychosis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). 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. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Competent and credible lay evidence may establish the presence of observable symptomatology and, in certain circumstances, may provide a basis for establishing entitlement to service connection. When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh the lay testimony and make a credibility determination as to whether it supports service connection. See, e.g., Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is therefore not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Nonetheless, although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, separated shoulder, pes planus (flat feet), tinnitus (ringing in the ears), varicose veins, etc., they are not competent to provide evidence on more complex medical questions beyond simple observations. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (indicating lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a 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). See also 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 aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Id at 1337. See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. The Veteran seeks service connection for an acquired psychiatric disorder, including PTSD. More specifically, he maintains that he began experiencing symptoms of his current disability in service, as a result of in-service stressors. Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2012). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(1) (2012); see also, 38 U.S.C.A. § 1154(b) (West 2002). Otherwise, the law requires verification of a claimed stressor. Where a determination is made that the Veteran did not "engage in combat with the enemy," or the claimed stressor is unrelated to combat, the Veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must include service records or other credible evidence that supports and does not contradict the Veteran's testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). In recent years, the regulations governing PTSD have been amended, effective July 13, 2010. 75 Fed. Reg. 39843 -52 (July 13, 2010). Specifically, this amendment eliminates the requirement for corroborating that the claimed in-service stressor occurred if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, provided that the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. Id. The Veteran in this case contends that his PTSD is related to his military service, and in particular, to events he experienced while serving in Korea. Service personnel records (SPRs) show that the Veteran served in Korea from May 1965 to June 1966 and was attached to the "HHC USA Ascom Depot (5757) APO 96220" as well as the "Co B USA Ascom Depot (5757) APO 96220." The Veteran's military occupational specialty was listed as "71N20," or movement specialist/freight-traffic agent. The Veteran's DD-214 form indicates that he was awarded the National Defense Service Medal and an Expert Rifle Badge. Service treatment records (STRs) reveal that the Veteran was afforded a clinical evaluation and physical examination in May 1964. The clinical evaluation was normal, and no psychiatric abnormalities were noted at that time. The Veteran described his health as "good," and provided a medical history in which he specifically denied ever having depression or excessive worry, or nervous trouble of any sort. The Veteran was also afforded a clinical evaluation and physical examination in March 1967 prior to separation from service. The clinical evaluation was normal, and no psychiatric abnormalities were noted at that time. The Veteran described his health as "very good (except a stomach ailment)," but provided a medical history in which he admitted to having depression. A notation on the report of medical history form described the Veteran's depression as on slight incidents, no treatment. The Veteran also provided a signed statement in August 1967 in which he stated that there had been no change in his medical condition since the examination. When seen at VA in March 2003, the clinician noted the Veteran's history of depression. VA treatment records associated with the Veteran's claims file show that the Veteran's wife left him in June 2002 because of his overuse of prescription medications. In addition, the Veteran's daughter died unexpectedly in June 2003. Following these unfortunate events, the Veteran was diagnosed in July 2003 as having depression and an adjustment disorder with depressed mood. There are no references to the Veteran's military service contained in these treatment notes. Rather, the Veteran sought VA care after experiencing difficulty coping with his daughter's death. Similarly, a December 2003 VA treatment note found the Veteran to have "major depression with possible psychotic features vs. complicated bereavement." In a VA mental health intake treatment note dated December 2003, the Veteran reported difficulty coping with his daughter's death. The Veteran also disclosed his service in Korea and reported flashbacks, nightmares, hypervigilance, and an exaggerated reaction. The examiner diagnosed the Veteran as having major depressive disorder, recurrent, severe with psychotic features, symptoms of PTSD, and bereavement. (Emphasis added). A VA mental health treatment consultation note dated February 2004 indicated that the Veteran continued to experience psychotic symptoms, including visual and auditory hallucinations. The Veteran reported anger about his daughter's death and threatened to harm the physician involved in her care at the time of her death. He also stated that he was never involved in combat or "firefights" in Korea, but that he witnessed the suicide of a friend who received a "Dear John" letter. The examiner diagnosed the Veteran as having depression with psychotic features. The Veteran stated in a March 2004 addendum that he was "in charge of convoys going into the DMZ" in Korea. The Veteran indicated that he saw a friend commit suicide after receiving a "Dear John" letter. The Veteran reported another in-service incident in which he allegedly carried another friend to the military police station after the friend overdosed on pills while intoxicated. The Veteran further indicated that while he was never in a position to receive incoming fire, the threat of incoming artillery fire was always imminent. The Veteran reported nightmares, flashbacks, hypervigilance, memory problems, an exaggerated startle response, and decreased interest in leisure activities. The Veteran noted that he kept several loaded weapons in the house, and that he would go on "patrol" with them at night. The examiner diagnosed the Veteran as having major depression with psychotic features as well as PTSD. A separate VA addendum also dated March 2004 indicated that the Veteran used his medications as a "crutch" to avoid dealing with his daughter's death. The Veteran underwent VA psychological testing in May 2004. The Veteran's scores on the Beck Depression Inventory were consistent with an extremely severe level of depression. The Veteran's score on the Mississippi Scale for Combat-Related PTSD was considered not consistent with a diagnosis of PTSD. (Emphasis added). However, the examiner noted that in light of the February 2004 VA treatment note which diagnosed the Veteran as having PTSD, the Veteran's Mississippi Scale score was deemed to be a "false negative, and it is further noted that his score on this instrument may have been depressed because his trauma does not derive from combat." The Veteran submitted a statement in support of the current claim to VA in May 2004. The Veteran stated that he had been treated for PTSD and he identified the following in-service stressors: I witnessed an MP commit suicide in August 1965 while stationed at ASCOM depot with HHC, 8th Army. I do not recall his name but do remember that he was Latin American. I also carried PFC [redacted] to the guard house at the depot after he attempted suicide by overdose. He had taken pills and had been drinking and was passed out when I found him. This occurred around Jan. - Mar. 1966. I also made 2-3 trips per month to the DMZ while assigned at ASCOM depot and felt my life was in danger on every trip. As noted above, the Veteran has been afforded multiple VA examinations with respect to his service connection claims. Significantly, an August 2010 VA examiner diagnosed PTSD based on the Veteran's reports of having witnessed a soldier commit suicide in service. The examiner opined that the Veteran's PTSD was as likely as not due to that event in service based on the rationale that the Veteran had consistently reported that event. In contrast, the examiner found that the Veteran had not consistently reported a service-related stressor of being shot at while serving in Korea along the demilitarized zone, and therefore, that reported stressor was not deemed credible by the examiner. While the August 2010 VA examiner found a positive nexus between the Veteran's current psychiatric disorder and his active service, the Veteran's reported stressor of witnessing a suicide in service has not been verified. Additionally, the August 2010 examiner's rationale that the service-related stressor of witnessing a suicide in service was consistently reported by the Veteran lacks support in the record. Although that stressor was reported during VA treatment as early as February 2004, VA treatment records dated from April 2001 to June 2010 show frequent mental health treatment with, at most, infrequent mention of that specific stressor, and only occasional reports of any military-related stressors. Therefore, the August 2010 VA opinion is insufficient to establish service connection for a psychiatric disorder. Regardless, a subsequent VA examiner found in September 2011 and February 2012 opinions that a diagnosis of PTSD was not warranted and questioned the prior diagnoses of PTSD in the record. Instead, the VA examiner diagnosed Major Depression and opined that the Veteran's Major Depression was less likely as not related to his active service. In support of that opinion, the examiner noted that the Veteran had suffered from depression since childhood and found that his military experiences appeared to have little effect on his life compared to familial issues post service. The VA examiner also noted in the February 2012 addendum that the Veteran had a significant history of substance abuse and that during the examination he did not mention any incident from service that was causing him to feel depressed or had ever caused him to feel depressed. Further, the examiner found that some of the Veteran's diagnosed depression was secondary to medication use and noted that his depression appeared to be in remission at the time of the February 2012 examination. Finally, the examiner noted that the preponderance of the evidence in the VA treatment notes indicated that the Veteran's depression was due to the death of his daughter. Therefore, the examiner opined that the Veteran's military service did not contribute to his depression and that the most likely causes of the Veteran's depressive symptoms were his lost relationships, his daughter's death, increased medical problems, and continued use or misuse of medication that increases depression. While the September 2011 and February 2012 VA examiner found that a diagnosis of PTSD was not warranted and further found that the Veteran's currently diagnosed Major Depression was not related to service, the examiner offered no discussion of the service treatment records, which show that that the Veteran reported "depression on slight incidents" during a March 1967 service examination. Nor did the examiner address the VA treatment notes which show occasional reports of nightmares of military trauma, including being shot at, and diagnoses of PTSD based on the Veteran's service-related stressors. In this regard, the VA treatment notes dated subsequent to the most recent February 2012 VA examination, show a diagnosis of PTSD based on the Veteran's report of being shot at in service. Therefore, the VA examiner's September 2011 and February 2012 opinions, standing alone, are an insufficient basis on which to deny the Veteran's claim. Parenthetically, the Board notes that in a September 2012 addendum opinion, a clinician at the Appeals Management Center indicated that the rebuilt claims file was reviewed and that the clinician was in agreement with the September 2011 and February 2012 VA examiner's findings. However, as that opinion was provided by a podiatrist, and not a psychiatrist or psychologist, and as there is no indication that the podiatrist was working under the close supervision of a psychiatrist of psychologist, or otherwise qualified to render a mental health opinion, the September 2012 opinion is inadequate and has no probative value. Significantly, the matter was remanded again in November 2012 to obtain a comprehensive psychiatric examination. The examiner was asked to reconcile the differing opinions of record, to review the claims file, and to provide an opinion as to the psychiatric disabilities from which the Veteran suffered, including but not limited to PTSD; and whether any diagnosed psychiatric disability, as likely as not, had its onset during service, clearly and unmistakably pre-existed service (and if so whether it was clearly and unmistakably not aggravated therein) and/or whether the Veteran psychiatric disability was otherwise related to service. The examiner was asked to address the March 1967 notation of depression and the Veteran's reports of being shot at in Korea. The Veteran was afforded a comprehensive VA examination by a qualified psychologist in February 2013. The examiner found diagnoses of adjustment disorder with anxious mood and alcohol dependence in full sustained remission. The examiner determined that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. The examiner indicated a review of the claims file, as well as electronic VA medical records. The examiner elicited a full and complete history of the Veteran's upbringing, education, work history, military history, and claimed stressors. According to the Veteran's self-reported history, the Veteran was physically abused by his father as a child. He got along fine with his mother and siblings. The Veteran described his multiple marriages and what led to the subsequent divorces. The Veteran reported that before service he received average grades in school and denied any significant problems in school. He worked on the family farm growing up. With regard to the Veteran's service, the examiner noted several reports by the Veteran that he had a "top secret" security clearance, according to the claims file and the VA medical records, but found no indication of such clearance in the SPRs. Post service, the Veteran reported that he graduated in accounting after going to school from 1969 to 1976. The Veteran reported a long work history and denied any psychiatric symptoms or trouble related to those jobs. Eventually he retired on disability due to a back disorder. The Veteran reported to the examiner that when he was a child he got sad and down when he did not get his way, and said it was more than other kids; however, he denied it lasted more than a day at a time or occurred very often. The Veteran denied significant anxiety as a child. He reportedly got angry some at his siblings, but was not sure it was worse than others or extensive. The examiner specifically noted the March 1967 in-service notation of current depressive or excessive worry, as well as the physician's summary indicating depression on slight incidences requiring no treatment. The examiner also noted that the Veteran's STRs did not show any evidence of depression, and National Guard records from his enlistment in 1975-1976 which contain an enlistment physical that did not show or note psychiatric issues at that time. The examiner specifically asked the Veteran about the entry in March 1967 regarding slight depression. The Veteran responded that he would get depressed in the military when he "couldn't achieve his goals." (Trying to make a certain rank, getting an article 15, etc.) None lasted more than a week or two per his own report and he let the issues resolve on their own. His mood would get better. Notably, the examiner found the Veteran's reports suggestive of minor episodes and did not reach clinical significance. The Veteran reported that he first sought treatment for alcohol problems in 1986, and then again in 1992, which no treatment prior to 1986 or between 1986 and 1992. The examiner noted the Veteran's post-service mental health treatment dating back to July 2001. The examiner referred to the December 2003 intake report summarized above, and specifically indicated that the Veteran was noted to have PTSD symptoms, but not a diagnosis of PTSD. The examiner also referred to a February 2004 PTSD assessment which revealed that the Veteran mentioned seeing a friend commit suicide by shooting himself; and, he carried a person passed out and overdosed on pills while intoxicated. He denied combat and stated that he "was never in a position to received incoming fire." Significantly, the examiner pointed out that this statement was in complete contrast to his current reports of taking sniper fire. The examiner, upon reviewing the record, noted that the Veteran was diagnosed with non-combat PTSD but was not treated in the PTSD problem for this reason. His PTSD diagnosis was variable for some time with depression the frequent diagnosis until a short time ago. Over time, according to the examiner, the Veteran's PTSD diagnosis re-emerged and he had further reports of sniper fire and other traumas including his report of seeing a suicide and carrying an intoxicated soldier. With regard to the current medical evidence of record, the examiner pointed to the July 2012 and September 2012 examination reports and specifically pointed out various inaccurate statements in those reports, opining that this was due to provider "cut and paste" errors. The Veteran reported that he began using alcohol at age 9 and continued through service until he went for substance abuse treatment in 1986. The Veteran also reported using other drugs, including marijuana, speed and prescription narcotics, all starting after service. With regard to stressors, the Veteran reported to the examiner that he was shot at in Korea in 1965 or 1966. While the examiner acknowledged that this stressor met the criterion A (that it is adequate to support a diagnosis of PTSD); and, that it is related to the Veteran's fear of hostile military or terrorist activity, the examiner found that the Veteran did not have a diagnosis of PTSD. Significantly, the examiner noted the Veteran's previously reported stressors, including the stressor of witnessing a suicide of a soldier, but indicated that the Veteran never mentioned this during the examination despite multiple probes. The examiner further pointed out that this stressor was the basis on which he met Criterion A for the original diagnosis of PTSD. The examiner specifically pointed out that the Veteran has not consistently reported the initial stressor over the years and thus it made the stressor more difficult to accept [as true]. The examiner indicated that the end of the interview was conducted in an open-ended manner to allow the Veteran to freely express himself so that the examiner could obtain the best information. When asked whether he had any additional symptoms or issues he wished to report that had not already been covered, the Veteran denied having anything to add about the present issues or symptoms. When asked if he had any concerns or complaints about the interview, the Veteran denied this. The examiner concluded the following: While there is significant evidence of a tendency to some irritability and anxiety prior to service as well as likely alcohol agues, it is not clear and unmistakable (obvious or manifest or undebatable) that a psychiatric disorder preexisted active service. Diagnosis with Rationale: 1. Adjustment disorder with anxiety is less likely than not related to or caused by military active service. A. The Veteran has other concerns that seem more pressing based on his presentation and review of notes, such as his frustration with the disability process, his concerns about his health and disability and worries about his finances. B. While his current symptoms as noted above are covered by a PTSD diagnosis based on the Veteran's subjective report, he has had significant inconsistency in his reports of trauma. At various times he has denied trauma in the military or not noted it, he has noted different traumas at different times, directly denied hostile fire at other times, and had given suicide as a trauma at one time but not on the day of examination, and in times past did not always report the sniper shot and in fact denied being under fire. The credibility of the Veteran's reports of trauma are in significant doubt. C. When the Veteran was first evaluated by a psychologist at the VA in a thorough interview, he did not report any trauma or unique symptoms and in his first encounters a few years later he was focused on his daughter's death and there was no mention of PTSD-like trauma symptoms. Again, this makes his reports of symptoms less credible. D. The Veteran reports of other distressing items over various times are not sufficient to support a Criterion A stressor for PTSD by DSM-IV definition. With regard to the Veteran's alcohol dependence, the examiner concluded that it was in full sustained remission, and therefore not a factor in his distress or impairment at present. It was less likely than not to be caused by or related to military active service. A. The Veteran began drinking significant possibly to abuse levels pre-military and increased to abuse levels prior to any stressor he claimed. B. He state to a large degree that he simply liked getting intoxicated. C. His alcohol problems have not appeared to vary based on any symptoms related to trauma over time. D. They have now resolved. The February 2013 examination and opinion is the most probative evidence of record. This examination report takes into account all of the prior medical history, and all of the Veteran's self-reported history over time. In reviewing this history, the examiner considered critical inconsistencies in the record regarding the Veteran's statements as to his stressors. The examiner also pointed out errors in the 2012 examination reports and provided a heavily detailed social, occupational, and medical history of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). This VA examiner's opinion is particularly probative as it was rendered by a person having the medical competence and qualifications to comment on these determinative issues of diagnosis and causation and contained the required discussion of the opinion's underlying medical rationale. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the probative value of medical opinion evidence is based on the personal examination of the patient, the knowledge and skill in analyzing the data, and the medical conclusion reached); see also Neives-Rodriguez (indicating most of the probative value of an opinion comes from its underlying reasoning, not just from mere review of the claims file, although that, too, has its importance if evidence in the file may affect the underlying basis of the opinion such as by revealing relevant facts). Although the Veteran is certainly competent to state that he is depressed or anxious, the VA examiner's opinion is more probative than the Veteran's personal assertions to the contrary because the examiner has medical expertise that the Veteran does not possess and has conducted a thorough review of the record. The Veteran is certainly competent to report psychiatric symptoms as noted above, but he is not competent to ascribe these symptoms to a particular diagnosis or, in turn, relate it to his military service, particularly when, as here, there is countervailing medical comment. The medical opinion is fully supported by the record. While the Veteran contends that he has PTSD due to in-service stressors, neither the STRs nor the SPRs support his statement. The examiner addressed the Veteran's report of depression in March 1967 and reported those findings on the examination report. The examiner concluded that the Veteran felt sad at times, but his symptoms did not rise to a level at that time that could be considered clinically significant. This finding is based in part on the Veteran's reports. Further, and significantly, the post-service record also does not reflect the diagnosis of a psychiatric disorder or treatment therefor for many years, again supporting the probative medical opinion. In sum, the VA opinion is more probative than the Veteran's statements. Significantly, the medical examiner questioned the credibility of the Veteran's reported stressors based on his inconsistent reporting. The Board can find no reason to disagree with the VA examiner in this regard. As noted by the examiner, the Veteran has, throughout the course of this appeal, provided different stressors at different times, and no stressor has been corroborated. The Veteran did not serve in combat with the enemy. The examiner addressed whether any psychiatric disorder had its onset prior to service, and found that none did because the Veteran's own self-reported history and symptoms regarding his reported "depression" at the time of discharge were not significant enough for the examiner to find that a chronic psychiatric disability existed at that time, or at any time prior to service. The examiner addressed whether any current psychiatric disorder was in any way related to service, and found that it was less likely than not (less than a 50 percent likelihood) that any psychiatric disorder was related to service. The examiner reasoned that other, more recent factors, as noted above, were far more likely to be the driving force behind his adjustment disorder, anxiety and depression. With regard to the conflicting medical evidence of record, any prior diagnosis of PTSD is of no value because the Veteran's statements regarding his stressors are found not credible and none have been verified or corroborated. Thus any diagnosis based on these stressors is inadequate for the purpose of a DSM-IV PTSD diagnosis. With regard to any psychiatric disorder other than PTSD, the negative evidence in this case far outweighs the positive. Based on the preponderance of the competent and credible evidence of record, no psychiatric disorder, however, diagnosed is etiologically related to service. As such, the evidence is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule, that is, other than to the extent mentioned. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance of the evidence instead is against the claim of service connection for an acquired psychiatric disorder, to include PTSD, so it must be denied. (CONTINUED ON NEXT PAGE) ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. ____________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs