Citation Nr: 1324087 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 06-34 296A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for cardiovascular disease, to include hypertension. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from November 1975 to August 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated April 2006 and December 2008 of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The April 2006 rating decision denied entitlement to service connection for a psychiatric disability and cardiovascular disease, to include hypertension. The December 2008 rating decision denied entitlement to service connection for PTSD. In April 2007, the Veteran testified at a personal hearing before a decision review officer. In May 2011, the Veteran presented sworn testimony during a personal hearing in Cleveland, Ohio, which was chaired by the undersigned Veterans Law Judge. Transcripts of both hearings have been associated with the Veteran's VA claims file. In December 2011, the claims were remanded for further evidentiary development. The VA Appeals Management Center (AMC) continued the previous denials in a November 2012 supplemental statement of the case (SSOC). In a February 2013 Board decision, the claims were again remanded for further development. As will be discussed below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The VA AMC issued a SSOC in May 2013 as to the pending claims. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The competent evidence of record does not support a finding that a psychiatric disability, including PTSD, had its clinical onset in service or is otherwise related to active duty. 2. The competent medical evidence of record does not support a finding that the currently diagnosed cardiovascular disease to include hypertension had its clinical onset in service or is otherwise related to active duty. CONCLUSIONS OF LAW 1. A psychiatric disability, including PTSD, was not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. §§ 1110, 1131, 1154(b), 5107 (West 2002 & West Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. Cardiovascular disease to include hypertension was not incurred in or aggravated by the Veteran's military service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & West Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA); Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & West Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a) (West 2002 & West Supp. 2012); 38 C.F.R. § 3.159(b) (2012). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (April 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the claimant to provide any evidence in the claimant's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) As to the pending claims, the Board finds that all notification and development action needed to arrive at a decision has been accomplished. Through notice letters dated in February 2006, January 2007, and September 2008 the RO notified the Veteran of the information and evidence needed to substantiate his claims. The Board also finds that the February 2006, January 2007, and September 2008 notice letters satisfied the statutory and regulatory requirement that VA notify a claimant which evidence, if any, should be obtained by the claimant and which evidence, if any, would be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C. F.R. § 3.159(b)). In the letters, the RO notified the Veteran that VA was responsible for obtaining relevant records from any Federal agency and that the RO would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Additionally, the notice letters requested the Veteran to submit medical evidence, opinions, statements, and treatment records regarding his disability. Consequently, a remand of this issue for further notification of how to substantiate the claims is not necessary. There is no indication that any additional action is needed to comply with the duty to assist in connection with the issue on appeal. The evidence in the claims file includes VA and private treatment records, statements from the Veteran, third party lay statements, Social Security Administration (SSA) records, service treatment records (STRs), and service personnel records. Significantly, the Veteran has not otherwise alleged that there are any outstanding medical records probative of his claims on appeal that need to be obtained. Thus, the Board finds that VA has properly assisted the Veteran in obtaining any relevant evidence. Additionally, the Veteran was afforded VA examinations in December 2011 as to both claims with additional VA medical opinions obtained in September 2012 and April 2013, the reports of which are of record. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examination reports and VA medical opinions relative to the both claims are sufficient, as they are predicated on consideration of the private and VA treatment records in the Veteran's claims file, as well as specific examination findings. The VA examiners considered the statements of the Veteran and third parties, and provided a rationale for the findings made, relying on and citing to the records reviewed, and they provided findings sufficient to apply the rating criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the pending claims has been met. 38 C.F.R. § 3.159(c)(4). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). A. Psychiatric disability to include PTSD. To establish entitlement to service connection for PTSD, the record must contain the following: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). If the alleged stressor is not combat-related, then a veteran's lay testimony, in and of itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates his testimony or statements. See Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996). In this case, the Veteran asserts that he developed PTSD during his military service that began following a personal assault. See, e.g., the Veteran's statement dated June 2006; the PTSD questionnaire dated July 2007; & the May 2011 Board hearing transcript. Specifically, the Veteran described an incident occurring in 1976 in which he was attacked by a "gang" of fellow service members and was nearly hit in the head with a wrench. Id. For the reasons set forth below, the Board concludes that service connection is not warranted. The Board notes that, with regard to stressor verification, the VA regulation at 38 C.F.R. § 3.304(f) was recently amended to liberalize the requirement of verification or corroboration of a veteran's claimed in-service stressor events in a PTSD claim. 38 C.F.R. § 3.304(f)(3), as added in 75 Fed. Reg. 39,843-852 (July 13, 2010). However these revisions do not pertain to claims for PTSD that, as here, are predicated on personal assault, combat, or prisoner of war (POW) experience since these type of claims already have their special provisions for establishing the occurrence of a stressor in these other type situations. The only notable change for claims predicated on personal assault was the redesignation of this type of claim from subpart (f)(4) to (f)(5). Under 38 C.F.R. § 3.304(f)(5), evidence of behavior changes following the claimed in-service assault may constitute credible supporting evidence of the stressor. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to, a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA may submit any evidence that it received to an appropriate mental health professional for an opinion as to whether it indicates that a personal assault occurred. With regard to personal assault cases, the United States Court of Appeals for Veterans Claims (Court) has held that "VA has provided special evidentiary development procedures, including the interpretation of behavior changes by a clinician and interpretation in relation to a medical diagnosis." Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996) (citing VA Adjudication Procedure Manual M21-1 (M21-1), Part III, 5.14c (8)-(9)) (later redesignated as Part VI, 11.38b(2), and now rescinded), aff'd 124 F.3d 228 (Fed. Cir 1997). The provisions of M21-1 (regarding special evidentiary procedures for PTSD claims based on personal assault) are substantive rules that are equivalent to VA regulations. YR v. West, 11 Vet. App. 393 (1998) & Cohen v. Brown, 10 Vet. App. 128 (1997). The Board notes that the aforementioned provisions of M21-1 have been rescinded and reissued as amended in a manual rewrite (MR). See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. D, Para. 17 (2006), entitled "Developing Claims for Service Connection for PTSD Based on Personal Trauma." Here, the Veteran's service records reveal that he received multiple non-judicial punishments for disobeying lawful orders. See the non-judicial punishments dated January 1977, March 1977, and April 1977. In July 1976, the Veteran received a mark of 2.8 in military appearance and adaptability. It was noted that his appearance is usually good "but sometimes falls outside of Navy Standards. He gets along reasonably well with others." In January 1977, the Veteran was similarly assigned a mark of 2.8 for military appearance and a mark of 2.6 for adaptability, which were explained as follows: "his appearance is rather careless, sometimes slovenly and unkempt, which is a cause for counseling and rebukes from superiors. He acts rashly and immaturely in dealings with shipmates, at times causing minor resentment or discontent. He is a glib speaker who occasionally uses this talent in attempting to sway the opinions of superiors. [He] has the ability to dramatically improve his performance, but must first overcome a poor attitude." The Veteran received a low rank in military behavior again in July 1977 at which time it was noted that "he shows no personal pride in tasks he accomplishes; nor in his appearance, which is not even close to minimum standards. His personal health habits are disgusting and constitute a burden to the morale of the supply compartment. His dealings with peers and seniors are characterized with selfishness and immaturity. He is unwilling, and I believe, unable, to accept or respect authority. Most any insignificant or change meeting with a superior becomes a demonstration of his disregard in this respect. His actions toward peers are sometimes rash, bullying and insensitive; he is not considered a good shipmate." Notably, the Veteran was seen in October 1976 for complaints that he wanted to get out of the Navy or transfer to the east coast in order to be closer to his parents due to their age-related health problems. A diagnosis of situational reaction was indicated. He was again seen in March 1977 for complaints of an inability to tolerate regimentation. It was reported that he had had a number of non-judicial punishments; the mental status interview showed normal findings. At that time, the Veteran reported that he was "chronically harassed as a consequence of his inability to prevent/avert verbalizing dissident sentiments." The impression was occupational maladjustment. The August 1977 separation examination did not reflect any documentation of an in-service physical assault or continuing psychological complaints. The Board notes that an August 1977 entry in the STRs reflects that apparently some of the Veteran's health records were lost while he was assigned to the U.S.S. MORTON. However, the Board observes that the claims file contains STRs dated prior to August 1977. Post-service treatment records dated March 2004 noted that the Veteran was having work-related stress and anxiety problems. An April 2004 VA treatment record documented continuing diagnoses of adjustment disorder with depression; rule-out bipolar disorder; alcoholic abuse. In January 2006, the Veteran filed a claim of service connection for psychiatric disability and cardiovascular disease, including hypertension. VA treatment records February 2006 documented a history of depression. In a May 2006 letter, VA physician Dr. C.L.W. reported that the Veteran "has been under my care in the Mental Health Clinic for the last four months. He is being treated for depression." Dr. C.L.W. further stated, "[i]n my professional opinion, based on reasonable medical probability, his depression is, as likely as not, directly related to his military service." At a June 2006 private psychological assessment performed by Dr. J.L.S., the Veteran reported that he was a victim of a gang attack during military service. He further reported experiencing some PTSD symptoms as a result of the attack. Dr. J.L.S. diagnosed the Veteran with major depressive disorder and PTSD. In a December 2006 treatment record, the treatment provider indicated that he explained to the Veteran that although the Veteran had a well-documented history of mental health treatment for depression dating back to March 2004, "he has not been given a PTSD diagnosis by any of these providers until Dr. W. did so in November of this year." The treatment provider indicated that the best diagnosis he could provide was "rule-out PTSD diagnosis." In a VA treatment record dated January 2007, the Veteran's treatment provider indicated "Veteran doesn't meet criteria for a diagnosis of PTSD because there wasn't enough evidence of trauma/symptoms to substantiate a diagnosis of PTSD." In a March 2008 letter, Dr. C.L.W. noted that the Veteran "has been consistent with his connection of depression combined with his inability to adjust to military service and is most common that the ability to communicate his mental feelings during duress is often difficult and most importantly somewhat embarrassing when contemplated coming forward to speak about such a condition." Dr. C.L.W. continued, "[h]e has been very candid and fits the common characteristics of depression associated with maladjustment during service with cardiac associated problems. High stress combined with physical and mental overload is as likely as not a contributing factor to his condition." In a March 2009 letter, Dr. C.L.W. opined that "[e]xisting military records reflect the continual problems adapting to military life. Notwithstanding, no prior record before service of civilian societal offenses. His PTSD cannot be discounted casually simply because it was not diagnosed in a timely fashion." In an August 2009 letter, Dr. C.L.W. stated "[m]y final diagnosis is service-connected PTSD with secondary major depressive disorder." In an August 2010 letter, Dr. P.W.S. noted the Veteran's report that he experienced a traumatic physical assault while in the Navy. Dr. P.W.S. diagnosed the Veteran with PTSD. In a July 2010 statement, VA social worker, R.H.M., indicated that, with respect to the conclusions set forth by Dr. C.L.W., "Dr. W. appears to be the most credible source of information about [the Veteran's] functioning, as Dr. W. has the most recent clinical contact with him and is monitoring his mental health treatment...Dr. W. is also eminently qualified to make this determination through training, certification, licensure, and experience." Mr. R.H.M. continued, "this writer feels confident [the Veteran] suffers from PTSD on an on-going basis. That he cannot definitively provide a Criterion A stressor due to loss of shipboard records which would tend to substantiate it should not be held against him." Pursuant to the December 2011 Board Remand, the Veteran was afforded a VA examination in December 2011 at which time the VA examiner interviewed the Veteran, reviewed the claims file, and diagnosed him with PTSD secondary to his trauma in the Navy. He stated, "[i]t is my professional opinion, that there is more than a 50% chance, or it is more likely than not, that his moderate PTSD that he is experiencing at the present time is related to his military service and was caused by the military service." However, this opinion was revised in a September 2012 addendum opinion in which the VA examiner noted "[t]he records overwhelmingly suggest that, if the Veteran does have PTSD, it is NOT caused by any alleged military stressor. Specifically, in-service medical treatment records from October 1976 stated, 'he is oriented and displays no mental illness,' while a medical record from March 1977 states 'there is no medical intervention indicated.' In addition, a medical questionnaire from August 1977 completed by the Veteran, shows that he indicated 'no' to questions about whether he was having problems sleeping, depression, or excessive worry, or as the questionnaire states, 'having nervous worry of any sort.'" The examiner further noted the Veteran's March 2004 VA treatments records which documented a diagnosis of adjustment disorder with depressed mood due to multiple stressors related to his work. The examiner concluded, "[t]herefore, given that there are no records that confirm an applicable stressor for Criterion A for a diagnosis of PTSD as required by the DSM-IV-TR, a diagnosis of PTSD as related to any particular claimed military stressor is not confirmed." The examiner continued, "[r]egarding the question of whether the Veteran suffers from a personality disorder, there is no history of documented personality disorder within the medical treatment records. Thus, no diagnosis of personality disorder is warranted at this time." The VA examiner further opined as to the conclusions of Dr. C.L.W., "[a]s no Criterion A stressor can be verified through military records, Dr. W.'s clinical opinion appears to be based solely on the Veteran's word. Thus, while the Veteran's self-report might be enough, from Dr. W.'s perspective, to medically treat the Veteran, the Veteran's word is not enough for Dr. W. to 100% accurately diagnose the Veteran. Thus, Dr. W.'s diagnosis of PTSD is not valid for VA rating purposes." With respect to the opinions rendered by Mr. R.H.M., the examiner stated, that Mr. M. did not assess the Veteran himself. "Therefore, his assessment that the Veteran has PTSD should not be considered valid and thus is no longer pertinent to the confluence of opinions in this matter." In a letter dated March 2013, Dr. P.W.S. stated, "[i]t is 100% as likely as not that [the Veteran's] disability results from the traumatic experience while in the Navy." Following the association of additional VA treatment records with the claims file, the Veteran was afforded another VA medical opinion in April 2013, at which time the psychologist noted diagnoses of major depressive disorder, PTSD, and adjustment disorder with anxiety. Following a thorough review of the claims file, the examiner stated, "[t]he records overwhelmingly suggest that, if the Veteran does have PTSD, it is NOT caused by any alleged military stressor." The examiner reiterated the findings expressed in the December 2011 addendum opinion noting the Veteran's STRs as well as initial March 2004 mental health treatment records which indicated that the Veteran was experiencing work-related stress. The examiner concluded, "given there are no records that confirm an applicable stressor for Criterion A for a diagnosis of PTSD as required by the DSM-IV-TR, a diagnosis of PTSD as related to any particular claimed military stressors is not confirmed." The examiner further opined, "[a]s there is no evidence whatsoever that a traumatic incident occurred during the Veteran's military service, any subsequent mental health diagnoses, including the Veterans' current mental health diagnoses, must have been acquired after his military service ended. Thus, it is 100% likely that any of the Veteran's current mental health diagnoses are directly and only related to post-military stressors the Veteran has endured." When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, a medical opinion based on an inaccurate factual premise is not probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. See Miller v. West, 11 Vet. App. 345, 348 (1998); see also Leshore v. Brown, 8 Vet. App. 409 (1995). To this end, the Board finds the September 2012 VA addendum opinion and April 2013 VA medical opinion probative as to the question of diagnosis and nexus as these opinions appear to have been based upon a thorough review of the record and thoughtful analyses of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Crucially, the VA examiner, who rendered the September 2012 and April 2013 opinions, concluded that the Veteran did not meet Criterion A for a DSM-IV complaint diagnosis of PTSD based upon his claimed in-service assault. Additionally, with respect to the other current psychiatric diagnoses, the VA examiner concluded that any such disabilities were unrelated to the Veteran's military service. These conclusions were rendered based upon review of the entire claims file and discussion of the clinical record. Moreover, the rationale set forth by the September 2012 and April 2013 VA examiner was substantial, thorough, and based on the overall record. Considering all evidence of record, the Board finds that the Veteran is not entitled to service connection for an acquired psychiatric disorder to include PTSD, to include as due to personal assault in service. Critically, the Board finds that the September 2012 and April 2013 VA medical opinions outweigh the opinions set forth by Dr. C.L.W. as well as Dr. P.W.S. Although these private and VA providers diagnosed PTSD based on alleged stressors during service, VA is not required to grant service connection just because a health care professional accepts a claimant's description of experiences during military service as credible and diagnoses PTSD. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). While the adequacy of a reported stressor to cause PTSD is a medical determination, the existence or occurrence of the event alleged as a stressor that caused PTSD is an adjudicative determination. Zarycki v. Brown, 6 Vet. App. 91, 97-98 (1993). Moreover, there is no indication that Dr. C.L.W. and Dr. P.W.S. had access to the Veteran's service records or any prior medical evidence to support the diagnosis. Additionally, the conclusions set forth by Dr. C.L.W. and Dr. P.W.S. provided little explanation for the conclusions that the Veteran suffers from psychiatric disabilities to include PTSD related to his military service. See Nieves-Rodriguez, 22 Vet. App. at 295; Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence); see also Jones v. Shinseki, 23 Vet. App. 382 (2010). The Board notes that the Veteran is competent to report that he was personally assaulted during service, because such alleged incidents are factual in nature and would be within his realm of personal experience. Barr, 21 Vet. App. at 307; Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). He is also competent to report an absence of observable symptoms of a mental health disorder after the alleged in-service incident, and treatment for such symptoms. Jandreau, 492 F.3d at 1376-77. However, VA adjudicators must determine whether competent evidence is credible, and weigh the lay and medical evidence submitted. VA may not determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence, but the absence of contemporaneous medical evidence may be weighed against the lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In determining credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). VA may not discredit testimony simply because the veteran is an interested party and stands to gain monetary benefits, but personal interest may affect the credibility. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Here, the Board finds the Veteran to be not credible with regard to the occurrence of the alleged personal assault, as his statements are inconsistent and are unsupported by the evidence of record. Notably, the Veteran has asserted that his assault occurred sometime in 1976. See the May 2011 Board hearing transcript, pg. 5. As noted above, STRs dated from October 1976 show the Veteran requested discharge or transfer as a result of his parents' health problems, which he contended were causing him stress. The Veteran's continued guilt with respect to his parents was again noted in March 1977 at which time he was diagnosed with 'occupational maladjustment' due to his repeated non-judicial punishments and difficulty interacting with peers and superiors. Accordingly, although the Veteran's service personnel records document in-service behavioral problems, these notations do not reflect a marked change in the Veteran's behavior but rather a progression of his poor military adaptability and inadequate adherence to military standards. When seeking treatment for psychiatric problems in 2004, the Veteran made no mention of inservice problems. He reported work-related stress and did not mention inservice stressors to medical providers until after he filed his claim for compensation in January 2006, when he was actively pursuing monetary benefits. Additionally, in order to establish service connection for PTSD, there must not only be competent and credible evidence of an in-service stressor, but also a current diagnosis under the DSM-IV standards which is based upon that stressor. The September 2012 and April 2013 VA examiner, whose findings the Board deems probative and persuasive, expressly concluded that the Veteran does not meet the DSM-IV criteria for PTSD or any disorder due to evidence of that he is not a credible reporter concerning the in-service assault. Moreover, as noted by the VA examiner in both the September 2012 and April 2013 opinions, while VA and private providers appear to have diagnosed PTSD based on the Veteran's reported stressor during service, this stressor has not been verified or corroborated. With respect to the other psychiatric diagnoses including major depressive disorder and adjustment disorder with depressed mood, the Board notes that the Veteran has submitted his own statements and personal testimony to support his claim of service connection. To this end, the Board notes that as a lay person, the Veteran is competent to testify to observable symptoms. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable symptoms of disability"); see also Barr, 21 Vet. App. 303, 312; Layno v. Brown, 6 Vet. App. 465 (1994). However, the Veteran is not competent to provide medical conclusions as to whether a disability is due to his military service. See Buchanan, 451 F.3d at 1331-37; see also Miller v. Derwinski, 3 Vet. App. 201, 204 (1992). Therefore, to the extent that the Veteran is claiming that he suffers from an acquired psychiatric disorder that is the result of his military service, laypersons without medical training, such as the Veteran, are not competent to comment on medical matters. See 38 C.F.R. § 3.159(a)(1). The Board further observes that the Veteran's contentions in support of service are contradicted by the September 2012 and April 2013 VA medical opinions, which specifically considered his lay assertions and any such inferences contained in the record in the negative nexus opinions. The Board is charged with weighing the positive and negative evidence; resolving reasonable doubt in the Veteran's favor when the evidence is in equipoise. Considering the overall evidence, including the post-service medical evidence, the September 2012 and April 2013 VA medical opinions, and the evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's claim that he suffers from an acquired psychiatric disorder, to include PTSD, which is related to his military service. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). B. Cardiovascular disease to include hypertension. As indicated above, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden, supra. Certain chronic diseases, including hypertension, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). With 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), 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. 38 C.F.R. § 3.303(b). For the showing of a '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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term 'chronic disease,' whether as manifest during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. See 38 U.S.C.A. §§ 1111, 1132 (West 2002); 38 C.F.R. § 3.304(b) (2012). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of "clear and unmistakable evidence"). It is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." See Cotant v. West, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. See VAOPGCPREC 3-2002; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Here, the Veteran has asserted entitlement to service connection for cardiovascular disease to include hypertension, which he contends is due to his military service. Specifically, the Veteran contends that he had hypertension upon his military enlistment that went untreated during his service. See, e.g., the May 2011 Board hearing transcript. The Veteran's service enlistment examination documented a blood pressure reading of 160/60 mm/Hg. However, a notation of "hypertension not confirmed" was further indicated. He was seen for complaints of dizziness in November 1975. A blood pressure reading of 130/80 was noted at the time and he was diagnosed with hyperventilation. In March 1977, a reading of 150/90 was indicated. Upon examination at separation from service in August 1977, the Veteran's blood pressure reading was 124/74 and his cardiovascular and nervous systems were listed as normal. In the August 1977 Report of Medical History, the Veteran denied that he had or had had heart trouble, or high or low blood pressure. As indicated above, the Board notes that an August 1977 entry in the STRs reflects that apparently some of the Veteran's health records were lost while he was assigned to the U.S.S. MORTON. However, the Board observes that the claims file contains STRs dated prior to August 1977. VA treatment records dated in April 1995 documented a blood pressure reading of 141/98 as well as the Veteran's complaints of dizziness and anxiety. A diagnosis of hypertension, "likely essential," was indicated in May 1998. In a March 2004 VA treatment record, it was noted that the Veteran was having work related stress that he believed caused his hypertension. In private treatment records dated January 2006, Dr. S.K. noted the Veteran's history of non-ischemic cardiomyopathy. Diagnoses of hypertension, coronary artery disease (CAD), and congestive heart failure were indicated in February 2006; a history of drug abuse was also indicated. In a March 2006 letter, Dr. S.K. noted the Veteran's history of nonischemic cardiomyopathy "that has persisted over the last few years and documented atrial fibrillation as well as ventricular tachycardia." The Veteran submitted an April 2007 journal article detailing mental stress-induced myocardial ischemia and cardiac events. In an April 2007 statement, the Veteran's spouse indicated that she had known the Veteran since 1978 and was aware that he was diagnosed with hypertension early in life. She indicated that he began seeing Dr. S. for treatment of hypertension soon after his military discharge. In an October 2006 letter, Dr. L.C. indicated that the Veteran has severe heart failure and a pacemaker. He further stated, "[t]his condition is as likely as not related to military experience." In a VA treatment note dated October 2006, Dr. L.C. reported that, according to the Veteran, his letter was apparently supposed to say that he has had hypertension since age seventeen. At the April 2007 RO hearing, the Veteran contended that his cardiovascular condition to include hypertension "has to do with high stress, exposure to asbestos, and depression." In a July 2007 letter, Dr. L.C. reiterated that the Veteran's cardiac disease "is as likely as not related to [his] military experience." In a March 2008 letter, Dr. C.L.W. opined that the Veteran's "[h]igh stress combined with physical and mental overload is as likely as not a contributing factor to his condition." In an August 2009 letter, Ms. K.T., C.R.N.P., indicated that the Veteran was diagnosed with non-ischemic cardiomyopathy in 2006 and an internal defibrillator was placed. She then opined, "[t]here is a possibility that untreated hypertension may have contributed to this condition." In a May 2010 letter, Ms. K.T. further concluded, "[a]fter reviewing [the Veteran's] entrance examination, he definitely exhibited signs of hypertension with multiple readings over 140 systolic. The most prudent evaluation would have been to provide hypertensive medication to control the hypertension or to provide medical follow-up once he was on active duty aggravation of this condition was possible during his military service due to an insufficient examination." This letter was also signed by Dr. S.N. In a March 2013 statement, Dr. P.W.S. indicated, "[i]t seems to me that there is a 70% chance that situational stress affects his hypertension and heart disease." The Veteran was afforded a VA examination with respect to the claimed hypertension in December 2011. Following interview and examination of the Veteran, as well as, review of his claims file, the examiner confirmed the diagnosis of hypertension. The examiner concluded, "[t]he claimed condition was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness." He explained, "[p]er claims file review, there is no evidence to support clinical diagnosis for hypertension during his military service." The Veteran was afforded another December 2011 VA examination with respect to his other cardiovascular conditions, which the examiner diagnosed as CAD, congestive heart failure, implanted cardiac pacemaker, cardiomyopathy, and cardiac dysrhythmia. The examiner then concluded, "[t]he claimed condition was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness." He stated, "[a] review of the Veteran's claims file has no evidence of any cardiac condition while on active duty." Pursuant to the Board Remand, the Veteran was afforded a VA addendum opinion in April 2013 following the association of additional medical records with the claims file. Upon review of the additional medical evidence, the examiner concluded that "[t]he claimed condition was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness." The examiner provided explained, "[a]lthough hypertension was considered prior to induction, no confirming evidence was found by the medical officer prior to induction. There was no hypertension found during military service. Hypertension was noted in 1994 and 1995, and he was treated. No cardiac disease of any kind was noted until 2003. Dates of active service are listed as 1975-1977. Accordingly, this consultant cannot agree that any cardiovascular disease was related to military service because of the length of time between dates of service and dates of the onset of cardiovascular disease." When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, a medical opinion based on an inaccurate factual premise is not probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. See Miller v. West, 11 Vet. App. 345, 348 (1998); see also Leshore v. Brown, 8 Vet. App. 409 (1995). In this matter, the medical evidence of record shows that the currently diagnosed cardiovascular disease including hypertension is not due to the Veteran's military service. Specifically, the Board finds the April 2013 VA medical opinion is probative as to the question of etiology, as it appears to have been based upon a thorough review of the record and provided detailed rationale based upon the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). As noted above, a preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. See 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). In the present case, the evidence shows that, although an elevated blood pressure reading was documented upon the Veteran's military enlistment, he was not diagnosed with hypertension at that time. See the enlistment examination dated October 1975. The Board recognizes that the Veteran has contended that he experienced hypertension prior to his military enlistment. See, e.g., the May 2011 Board hearing transcript. To this end, the Board notes that lay statements submitted by the Veteran concerning a pre-existing condition are not sufficient to rebut the presumption of soundness. See Gahman v. West, 13 Vet. App. 148 (1999) (recorded history provided by a lay witness does not constitute competent medical evidence sufficient to overcome the presumption of soundness, even when such is recorded by medical examiners). Moreover, the multiple opinions from Ms. K.T. in support of aggravation of a pre-existing hypertensive disorder are insufficient to resolve the question of whether the presumption of soundness should apply in this matter as the conclusions rendered therein were admittedly speculative and were not supported by any rationale. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence). The Court held in Jones v. Shinseki, 23 Vet. App. 382 (2010) that in order to rely upon a statement that an opinion cannot be provided without resorting to mere speculation, it must be clear that the procurable and assembled data was fully considered and the basis for the opinion must be provided by the examiner or apparent upon a review of the record. To this end, the Board notes that the opinions expressed in the August 2009 and May 2010 letters from Ms. K.T. are admittedly speculative as to the question of a pre-existing cardiovascular disorder. Significantly, as discussed above, although the Veteran had an elevated blood pressure reading at the time of his enlistment examination, a finding of hypertension was not confirmed. Moreover, the April 2013 VA medical opinion specifically noted that the Veteran was not diagnosed with hypertension prior to his military enlistment. The competent medical evidence of record therefore supports a finding that the Veteran was sound upon his military enlistment. Thus, the presumption of soundness has not been rebutted. See 38 U.S.C.A. § 1111 (West 2002); see also Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991); 38 C.F.R. § 3.304(b) (2012). Moreover, the competent medical evidence of record demonstrates that the currently diagnosed cardiovascular disease to include hypertension is not attributable to his military service. Crucially, the April 2013 VA examiner concluded that the Veteran's currently diagnosed cardiovascular disease to include hypertension did not manifest in service and was, in fact, unrelated to the Veteran's military service. This conclusion was rendered based upon review of the entire claims file and discussion of the clinical record. In addition, the rationale set forth by the April 2013 VA examiner was substantial, thorough, and based on the overall record. The Veteran has not produced a medical opinion to contradict the conclusion set forth by the April 2013 VA examiner concerning the issue of medical nexus. With respect to the medical treatise evidence submitted by the Veteran, which discusses the impact of psychiatric symptomatology on blood pressure, this evidence is of little probative value as it is nonspecific to his case. In contrast, the April 2013 VA examiner thoroughly considered the Veteran's medical history in rendering his medical nexus opinion. As was explained in the VCAA section above, the Veteran has been afforded ample opportunity to present competent medical evidence in support of his hypertension claim. He has not done so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is the claimant's responsibility to support a claim for VA benefits). Thus, the April 2013 VHA medical opinion stands unchallenged as competent medical evidence on these crucial questions of medical nexus. The Veteran has submitted his own statements as well as third party lay statements from his spouse to support his claim of service connection. As lay persons, the Veteran and his spouse are competent to report observable symptoms. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, an appellant is competent to provide information regarding visible, or otherwise observable symptoms of disability); see also Barr, supra; Layno v. Brown, 6 Vet. App. 465 (1994). However, neither the Veteran nor his spouse is competent to provide medical conclusions as to whether a disability is due to his service-connected disabilities or his military service. See Buchanan v. Nicholson, 451 F.3d 1331-37 (Fed. Cir. 2006); see also Miller v. Derwinski, 3 Vet. App. 201, 204 (1992). Therefore, to the extent that the Veteran is now claiming that his cardiovascular disease to include hypertension is the result of his military service or is caused or aggravated by his military service, laypersons without medical training, such as the Veteran and his spouse, are not competent to comment on medical matters. See 38 C.F.R. § 3.159(a)(1) (2012). The Board further observes that the Veteran's contentions in support of service connection including as to dependent and/or aggravated symptomatology are contradicted by the findings of the April 2013 VA examiner who specifically considered the Veteran's lay assertions and any such inferences contained in the record in rendering the negative nexus opinion. To the extent that the Veteran is contending that his cardiovascular disease including hypertension manifested during his military service and continued thereafter, the Board finds that he is competent to report having certain observable symptoms such as elevated blood pressure since service. Competent testimony is limited to that which the witness has actually observed, and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses, that which is heard, felt, seen, smelled or tasted. Layno, supra. Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the later is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker, supra; Layno at 469; see also Cartwright, supra. In this regard, the Board recognizes that the Veteran was found to have an elevated blood pressure reading of 160/60 at the October 1975 enlistment examination. However, it was specifically noted that a diagnosis of hypertension was not confirmed. Additionally, although a blood pressure reading of 150/90 was indicated in March 1977, no diagnosis of hypertension was demonstrated upon the Veteran's separation from service in August 1977. Moreover, there is no indication in the medical evidence of record that he was diagnosed with hypertension during his military service or for years thereafter. The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan, supra. Additionally, the Board recognizes that as with 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), 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. 38 C.F.R. § 3.303(b). Crucially, as indicated by the April 2013 VA examiner, the evidence does not document a diagnosis of hypertension or any other cardiovascular condition until the 1994. C.f., Walker, 708 F.3d at 1331. Moreover, the Veteran's separation examination was normal and he denied elevated blood pressure or related problems at that time. Accordingly, the Board finds that the reported history of continued symptoms dating from the period of active service to present is not credible. The Board is charged with weighing the positive and negative evidence; resolving reasonable doubt in the Veteran's favor when the evidence is in equipoise. Considering the overall evidence, including the post-service medical evidence, the uncontradicted April 2013 VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the contentions that the Veteran's current cardiovascular disease to include hypertension is related to active military service. Thus, the benefit-of-the-doubt rule is not helpful to the Veteran. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for an acquired psychiatric disorder to include PTSD is denied. Entitlement to service connection for cardiovascular disease to include hypertension is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs