Citation Nr: 1323643 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 05-38 032 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Massachusetts Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to October 1968. This appeal to the Board of Veterans' Appeals (Board) arose from a September 2005 rating decision in which the RO denied service connection for PTSD. In November 2005, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in November 2005, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) later that month. In November 2006, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In a June 2007 decision, the Board denied service connection for PTSD. The Veteran, in turn, appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2008 Order, the Court granted a Joint Motion (filed by representatives of both parties) to vacate and remand the June 2007 Board decision, and returned this matter to the Board for further proceedings consistent with the Joint Motion. In February 2010, the Board remanded the claim for service connection for PTSD to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further development. After completing the requested development, the RO continued to deny the claim (as reflected in an October 2010 supplemental SOC (SSOC)), and returned this matter to the Board for further appellate consideration. In a September 2011 decision, the Board denied service connection for PTSD. The Veteran, in turn, appealed the Board's decision to the Court. In a June 2012 Order, the Court granted a Joint Motion (filed by representatives of both parties) to vacate and remand the September 2011 Board decision, and returned this matter to the Board for further proceedings consistent with the Joint Motion. In September 2012, the Board remanded the claim for service connection for PTSD to the RO, via the AMC, for further development. After providing development, the RO continued to deny the claim (as reflected in a February 2013 SSOC), and returned this matter to the Board for further appellate consideration. In April 2013, the Board determined that the current appeal is limited to the issue of service connection for PTSD and remanded the claim for service connection for PTSD to the RO, via the AMC, for additional development. After providing that development, the RO continued to deny the claim (as reflected in a May 2013 SSOC). The RO again returned this matter to the Board for appellate consideration. In June 2013, the Veteran submitted additional evidence and argument in support of his claim on appeal. Prior to the receipt of that evidence, in June 2013, the Veteran provided a waiver of initial RO consideration for any future evidence submitted. See 38 C.F.R. § 20.1304 (2012). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the documents in such file reveals that some of the documents in the Virtual VA paperless claims file, i.e., VA treatment records dated from February 2013 to March 2013, are relevant to the issue on appeal and are not duplicative of the evidence in the paper claims file. However, as such evidence was considered by the RO in its preparation of the May 2013 SSOC, there is no prejudice to the Veteran in the Board proceeding to a decision, at this juncture. The Board again notes that the RO, in a January 2009 rating decision, found that new and material evidence had not been submitted sufficient to reopen the claim for service connection for major depressive disorder with psychotic features (filed in October 2008). In April 2010, the Veteran filed a NOD with that decision. In correspondence dated in April 2010, the RO advised him that his NOD was not timely. See 38 C.F.R. § 20.302. The Veteran did not appeal that timeliness determination. However, the Board found, in September 2011, that the untimely April 2010 NOD can be construed as a request to reopen a claim for service connection for a psychiatric disorder other than PTSD. The Board further determined that since the RO had not adjudicated that request, which matter was not before the Board. The Board referred that issue to the RO for appropriate action. It does not appear that the RO has addressed that claim since the April 2013 Board decision. As such, this matter is still not properly before the Board, and is, again referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim for service connection for PTSD have been accomplished. 2. Although the record reflects assessments of PTSD, the weight of the competent, persuasive evidence establishes that the Veteran does not meet the diagnostic criteria for PTSD and has not met them at any point pertinent to this appeal. CONCLUSION OF LAW The criteria for service connection for PTSD are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 have been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339(Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a May 2005 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for service connection for PTSD, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The September 2005 rating decision reflects the initial adjudication of the claim after issuance of the May 2005 letter. Post rating, in a March 2006 letter, the RO notified the Veteran of information pertaining to the assignment of disability ratings and effective dates. The timing of this notice is not shown to prejudice the Veteran. The Board is denying the claim for service connection. As such, no effective date or higher rating is, or will be, assigned. Accordingly, there is no possibility of prejudice to the veteran under the notice requirements of Dingess/Hartman. Furthermore, the RO has readjudicated the Veteran's claim multiple times following the September 2005 rating decision, in a September 2005 SOC, October 2010 SSOC, February 2013 SSOC and May 2013 SSOC. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent evidence associated with the claims file consists of in- and post-service treatment records, including records from the Social Security Administration (SSA). Also of record and considered in connection with the appeal is the transcript of the November 2006 Board hearing, along with various statements by the Veteran. The Board finds that no further action in this appeal, prior to appellate consideration, is required. The Board is satisfied that the development ordered in the prior September 2012 and April 2013 remands has been accomplished. In September 2012 and April 2013, the Board remanded to obtain VA medical records from the Providence VA Medical Center (VAMC). Those records are associated with the virtual claims file. At those times, the Board also remanded to provide the Veteran the opportunity to identify additional pertinent evidence. The AMC provided that notice in January and April 2013 letters. Additionally, in September 2012, the Board remanded to provide notice of how to substantiate a claim for service connection for PTSD under the revised version of 38 C.F.R. § 3.304(f). The January 2013 letter also included that notice. In January 2013, the Board further remanded to obtain a new VA examination, which the Veteran underwent in February 2013. In April 2013, the Board requested an additional medical onion from the February 2013 VA examiner. That VA examiner provided the requested opinion in May 2013. Furthermore, as regards the November 2006 hearing , the Board notes that, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the individual who chairs a hearing fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, the undersigned Veterans Law Judge identified the issue on appeal. The parties to the June 2012 Joint Motion for Remand noted that the Veterans Law Judge did not explain the issues material to substantiating the claim, under Bryant. Although the Veterans Law Judge did not solicit the identification evidence relevant to the claim, the Board notes that the Veteran had previously reported treatment from the VAMC and that those records are associated with the claims file. In the September 2012 remand, the Board also directed the RO to inform the Veteran to identify or submit evidence concerning whether has PTSD as a result of his identified stressors. The RO provided that notice in January 2013. The Veteran did not respond to that request. Furthermore, consistent with the prior two Board remands, the RO requested PTSD treatment information from the Veteran in January and April 2013 letters. The Veteran did not respond to those requests. Moreover, the Board notes that during the November 2006 Board hearing the Veteran's representative indicated actual knowledge of the evidence necessary to support the Veteran's claim, when he specifically noted that the Veteran did not have a diagnosis of PTSD. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims decided herein. As such, the Board finds that, any errors with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant, have been cured. In summary, the duties imposed by the VCAA have been considered and satisfied. Through identified notice, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). On July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the occurrence of the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010) and 75 Fed. Reg. 41092 (July 15, 2010) (correcting the effective and applicability dates from July 12, 2010 to July 13, 2010). The revisions apply to, among others, claims appealed before July 13, 2010, but not yet decided by the Board. In this case, however, the Veteran has not met the first essential criterion for service connection for PTSD-medical diagnosis of the disorder in accordance with the applicable diagnostic criteria. As such, further discussion of the recent revisions to 38 C.F.R. § 3.304 is unnecessary. Diagnoses of PTSD must be rendered in accordance with the diagnostic criteria for the condition set forth in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). Considering the pertinent evidence in light of the above, the Board finds that the weight of the competent, persuasive medical evidence establishes that the Veteran does not meet the diagnostic criteria for PTSD. Therefore, the claim must be denied. The Veteran's service treatment records are negative for any finding or diagnosis of PTSD. Psychiatric evaluation was normal at the time of his separation from service in October 1968, though the Veteran noted (in his Report of Medical History) that he had nervous trouble. A September 1996 Access to Psychiatry Initial Evaluation Report documents a diagnosis of depression. In July 1998, the Veteran was admitted to the Partial Hospital Program at Butler Hospital in Providence, Rhode Island, for psychiatric treatment. Associated records indicate, that, on admission, he reported growing increasingly depressed over the prior three months. He also described a delusional belief that people were sending him messages about a child that he had allegedly fathered in Vietnam. The discharge summary noted that the Veteran had left after participating in the program for one day, and that mental status at the time of discharge could not be assessed. The principal diagnosis was psychotic disorder, NOS (not otherwise specified). An August 1998 VA discharge summary documented that the Veteran had been discharged home with a diagnosis of bipolar disorder, type I, current episode mixed. In February and April of 2000, a VA medical provider noted that the Veteran endorsed PTSD symptoms, including hypervigilance, avoidance behaviors and distressing recollections of his time in Vietnam, including combat exposure and atrocity exposure. The medical provider diagnosed the Veteran with major depression disorder, with severe recurrent psychotic features and PTSD. However, in May 2000, that same VA medical provider found the Veteran to only have severe major depressive disorder, with psychotic features. In November 2000, the Veteran underwent a VA examination. The examiner diagnosed the Veteran with major depressive disorder, with psychotic features, in partial remission. A February 2003 VA medical record documents a diagnosis of major depressive disorder with psychosis, general anxiety disorder and rule out bipolar disorder. A February 2004 VA medical record documents that the Veteran complained of problems sleeping and that he would have "not so much flashbacks but things that happened when I was in Vietnam." The VA medical provider diagnosed the Veteran with a psychotic disorder, NOS, and a history of severe, recurrent major depressive disorder, with psychotic features; rule out bipolar disorder, NOS. In May 2004, a VA medical provider found that a PTSD screen for the Veteran was positive and ordered a psychology consult. In June 2005, the Veteran underwent a VA examination. The examiner noted that although the Veteran's combat stressors had not been verified, the Veteran's service in Vietnam showed that it was as likely as not that the Veteran was exposed to stressful incidents. The examiner specifically considered all the criteria necessary for a diagnosis of PTSD. Following examination of the Veteran and an in-depth discussion of the records of evidence, the examiner found no evidence of a diagnosis of PTSD and no indication that the Veteran's exposure to stressors in Vietnam had been linked to his psychiatric symptoms. The June 2005 VA examiner explained that the Veteran did not meet the criteria for PTSD. The examiner found that the Veteran did not indicate any significant difficulties with intrusive thoughts (except when he had psychotic episodes) or distress associated with trauma-related triggers. The examiner noted that the Veteran reported that bad dreams about Vietnam only occurred two or three times a year. The examiner found that the Veteran only indicated mild avoidance with some restriction of affect and detachment, but without significant isolation and without significant avoidance of reminders of his Vietnam experiences. The examiner also noted mild sleep disturbance, but that the Veteran was able to sleep seven to eight hours nights and not feel fatigued. The Veteran also indicated that he did not have irritability or anger problems, hypervigilance or exaggerated startle response. Furthermore, although the Veteran linked his suspiciousness with his difficulty to trust people in Vietnam, the examiner found no evidence to link the Veteran's experiences in Vietnam to the Veteran's psychiatric symptoms. The June 2005 VA examiner found that the Veteran had a psychotic disorder, which at times was associated with mood disorder symptoms. However, the examiner found that "it is less than likely as not, based on the available evidence, that his psychotic disorder and/or mood disorder was associated with his exposure to stressors in Vietnam." In a June 2005 statement, the Veteran's wife reported that Dr. Garcia has stated that the Veteran has symptoms of PTSD. She contends that prior to his VA hospitalization the Veteran had "episodes" related to Vietnam. In October 23, 2008, the Veteran received a VA mental health consult for a PTSD assessment. The October 26, 2008 addendum document that the Veteran underwent a comprehensive biopsychosocial assessment. Following testing, the VA medical provider diagnosed the Veteran with major depressive disorder, severe, with psychotic features, psychosis, NOS and rule out schizoaffective disorder. The October 2008 VA medical provider specifically found that the Veteran did not have trauma consistent with Criteria A for PTSD. She then explained that even if she accepted the Veteran's stated stressor events as possible Criteria A events, she still found that the Veteran did not meet the other criteria for a PTSD diagnosis. An October 2010 VA medical record documented a diagnosis of psychosis vs. schizoaffective disorder. The VA medical provider found that it was unclear whether the Veteran met the criteria for a schizoaffective disorder diagnosis. In a January 2013 letter (received by VA in March 2013), the Veteran's spouse recounted her history with the Veteran, including his relationship with his family and her observances of his behavior. In a January 2013 letter (received by VA in March 2013), the Veteran reported on his experiences in Vietnam and his reported psychiatric symptoms since that time. A February 2013 VA medical record documented a diagnosis of psychosis. In February 2013, the Veteran underwent another VA examination. The VA examiner specifically found that the Veteran did not have a diagnosis of PTSD that conforms to DSM-IV criteria. The February 2013 VA examiner described the Veteran's medical history and noted that the Veteran's regular VA medical provider continued to diagnose the Veteran with psychosis, NOS. The examiner further noted that the October 2008 comprehensive biopsychosocial assessment resulted in a diagnosis of major depressive disorder with psychotic features and psychosis, NOS. In considering PTSD diagnostic criteria, the February 2013 VA examiner found that the Veteran did not have exposure to a traumatic event, that the traumatic event was not persistently experienced, that the Veteran did not have persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness and that there was no persistent symptoms of increased arousal. The VA examiner specifically found that the Veteran did not meet the full criteria for a PTSD diagnosis. The February 2013 VA examiner noted that the Veteran's claimed in-service stressful incidents had a powerful impact on him and more likely than not he memories of these events are triggered by certain environmental stimuli. However, the examiner found that the nature, frequency and severity of the Veteran's psychiatric symptoms "do not meet the DSM-IV criteria" for PTSD. Rather, the examiner found the Veteran's psychiatric symptoms meet the DSM-IV criteria for psychotic disorder, NOS. In May 2013, the February 2013 VA examiner again reviewed the Veteran's claims file. The examiner again found that the Veteran's claimed PTSD was less likely or not incurred in or caused by claimed in-service injury, event or illness. The examiner explained that the Veteran's and his wife's respective statements (the letters received by VA in March 2013) were consistent with mental and behavioral problems, but were not discriminatively diagnostic of PTSD. Furthermore, the VA examiner found that the February through April 2000 VA medical records only documented a secondary diagnosis of PTSD; the Veteran's primary diagnosis was major depressive disorder with psychotic features. The examiner found that in those VA medical records, there was no documented assessment of PTSD. Additionally, the May 2000 VA medical record, by the same psychiatrist that had previously diagnosed PTSD in February and April 2000, indicated that the psychiatrist had discontinued the secondary diagnosis of PTSD. Furthermore, the subsequent October 2000 VA medical record documented that the Veteran was not reporting PTSD symptoms. The VA examiner also noted that the May 2004 VA medical record reported that the "PTSD screen was positive" but that the psychiatrist writing that note only documented a diagnosis of "Psychotic Disorder NOS." Additionally, the follow-up June 2004 VA medical record reported that "the PTSD screen was negative." In his May 2013 opinion, the February 2013 VA examiner found that following review of the Veteran's records and his February 2013 VA examination report, "the Veteran's psychiatric symptoms do not meet the DSM-IV criteria for Posttraumatic Stress Disorder." The above-cited evidence reflects that the record contains conflicting medical opinions on the question of whether the Veteran has actually met the diagnostic criteria for PTSD both prior to, and during, the appellate period. The Board points out, however, that even if the Veteran experienced PTSD, meeting diagnostic criteria, in the past, he is not entitled to service connection for a disability that did not exist at the time he filed his claim for service connection or at any time during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (citing Gilpin v. West, 155 F.3d 1353 (F.3d 1998); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997)). It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). However, a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board finds that the February 2013 VA examiner (who also provided the May 2013 addendum opinion) medical opinions-that the Veteran did not meet the full criteria for a PTSD diagnosis-are the most probative medical opinions on this point. The examiner conducted in-depth interviews with the Veteran and reviewed his treatment history and claims file, conducted thorough psychometric testing, described his symptoms, and provided reasoned analyses pursuant to the specific diagnostic criteria set forth in DSM-IV. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). Further, the examiner was a VA PTSD examiner, and the United States Court of Appeals for the Federal Circuit has held that the Board may assume VA medical examiners are competent. See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2009) (applying the presumption of regularity to VA medical examiners in the discharge of their official duties). The Board finds the February 2013 VA examiners' opinions on the matter of diagnosis highly probative. The Board notes that although the June 2005 VA examiner also provided probative evidence in the present claim, the parties to the June 2012 Joint Motion for Remand found that VA examination to be inadequate, because it failed to take into account the previous assessments and positive screen for PTSD. The February 2013 VA examiner, however, specifically noted consideration of and discussed the VA medical records documenting a previous diagnosis of PTSD and the positive PTSD screen (which the parties to the June 2012 Joint Motion for Remand indicated the June 2005 VA examiner had failed to consider). The February 2013 VA examiner also specifically considered and discussed the lay statements made by the Veteran and his spouse. Additionally, the February 2013 VA examiner had the opportunity to review all the medical evidence of record, including the SSA records that had not been associated with the claims file at the time of the June 2005 VA examination (which the parties to the June 2012 Joint Motion for Remand had indicated was not associated with the claims file). The only medical evidence of record reflecting diagnosis of PTSD consists of outpatient treatment records from the VA Medical Center in Providence. Those February and April 2000 VA medical records did not occur during the appellate period. The Board acknowledges, as the Veteran contended in his June 2002 Joint Motion for Remand, that these records do reflect a diagnosis of PTSD. However, the Board notes that these outpatient treatment notes do not actually reflect diagnosis based on evaluation, and that subsequent records do not continue that diagnosis. Indeed, the later October 2008 VA mental health consult addendum that actually included a biopsychosocial assessment specifically found that the Veteran did not meet the DSM-IV criteria for PTSD. The February 2013 VA examiner, in his May 2013 addendum opinion, similarly noted that those few occasions where a VA medical provider noted a diagnosis of PTSD had not been based on evaluation and that the VA medical provider would subsequently drop the diagnosis of PTSD in later medical records. The February 2000 and April 2000 VA medical records do reflect some evaluation of the Veteran as well as diagnosis of PTSD and, pursuant to Cohen v. Brown, 10 Vet. App. 128, 140 (1997), VA may presume that a diagnosis made by a mental health care professional was made in accordance with the DSM-IV. However, review of these notes of consultation and diagnosis reflect that the Veteran saw the same VA medical provider (VA psychiatrist) in May 2000 and the diagnosis of PTSD was dropped and his only mental health diagnoses were major depression disorder with Psychotic features (as also noted by the February 2013 VA examiner in his May 2013 addendum opinion). Furthermore, that same VA medical provider noted in October 2000 that the Veteran denied PTSD symptoms. Similarly, although a May 2004 VA medical record document a positive PTSD screen, the February 2013 VA examiner, in his May 2013 addendum opinion, found that a follow-up VA medical record in June 2004 reported a negative PTSD screen. Further, review of the VA medical records also fail to indicate that any of the VA medical providers had access to the Veteran's full treatment history as did the VA examiners. The VA examiners' review of the Veteran's claims file and treatment record add probative weight to their opinions. Indeed, the February 2013 VA examiner had the most complete review of the record, as he also considered the medical evidence of record and the additional lay statements made by the Veteran and his spouse (that were received in March 2013 following the February 2013 VA examination) in forming his May 2013 addendum opinion. Although the Court held in Nieves-Rodriguez, supra, that review of the claims file is not the determinative factor in assigning probative value, it observed the importance of a physician's knowledge of relevant case facts. The February 2013 VA examiner demonstrated such knowledge by reviewing the Veteran's clinical history. Furthermore, the February 2013 VA examiner specifically observed the Veteran's prior mental health diagnoses, including PTSD, and the lay statements of record. The examiner's conclusions were based on a thorough review of the Veteran's clinical history and treatment during the appellate period which makes them highly probative. Further, the February 2013 VA examination reports reflect analyses supporting the diagnostic opinions. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion 'must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.') In particular, the February 2013 VA examiners expressly stated that the Veteran's symptoms did not meet diagnostic criteria for PTSD and provided paragraphs of reasoning as to how and why his symptoms supported diagnoses of non-PTSD psychiatric disorders. Also of note, the February 2013 VA examination reports reflect application of multiple tests and analysis of multiple diagnostic criteria whereas the positive VA medical records notes reflect only limited interviews of the Veteran. The Board notes that the June 2005 VA examiner had made similar findings, though based on his more limited review of the record. Furthermore, 2000 VA medical records developed after a VA medical provider noted a PTSD diagnosis stopped including such a diagnosis. Moreover, the October 2008 VA medical record developed to specifically provide a biopsychosocial assessment specifically found that the Veteran did not meet the criteria for PTSD under DSM-IV. In short, the most persuasive opinion evidence weighs against the existence of a current diagnosis of PTSD, and ultimately, the claim. Owens, 7 Vet. App. at 433. In addition to the VA medical evidence of record, the Board has considered the private medical evidence submitted by the Veteran as well as the assertions of the Veteran and those advanced on his behalf. However, the private treatment evidence does not include a diagnosis of PTSD by his private medical providers. The Board notes that in her June 2005 statement, the Veteran's wife reported that a Dr. Garcia had stated that the Veteran had symptoms of PTSD. The Board notes, however, that the question is whether the Veteran meets the criteria for a DSM-IV diagnosis of PTSD. In this regard, a layperson's account of what a doctor purportedly said is too attenuated and inherently unreliable to constitute 'medical' evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (Veteran's statement that his physician told him that he "most probably" had diabetes at time of his discharge from service was not sufficient medical evidence to establish service connection for diabetes). Further, the lay statements submitted by the Veteran do not constitute probative medical evidence. 38 C.F.R. § 3.159(a) (1). Although claimants are competent to describe their symptoms, a layperson is generally not capable of opining on matters requiring medical knowledge. See Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997). PTSD is a complex psychiatric disability that cannot be diagnosed without special knowledge, training, and experience. See Kahana v. Shinseki, 24 Vet. App. 428, 433, 438 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As the Veteran and his spouse are not shown to have the knowledge, training and expertise to diagnose PTSD, their lay assertions on the question of medical diagnosis of PTSD have no probative value. Moreover, the February 2013 VA examiner specially considered lay statements of record (in his May 2013 addendum opinion) and found that such information was consistent with mental and behaviorally problems, but was not discriminatively diagnostic of PTSD. As the preponderance of the competent, probative evidence establishes that the first, essential criterion for service connection for PTSD-medical diagnosis of the disorder in accordance with the DSM-IV-is not met, service connection for PTSD cannot be established, and the Board need not address the remaining criteria for service connection for PTSD. See 38 C.F.R. § 3.304(f). For all the foregoing reasons, the Board finds that the claim for service connection for PTSD must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for PTSD is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs