Citation Nr: 1324092 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 06-18 495 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include major depressive disorder. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty for training from July to December 1961, and on active duty from August 1963 to August 1966. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied the benefits sought on appeal. This case was previously before the Board in May 2009 when service connection was denied for PTSD and nerve problems, to include adjustment disorder and depression. In June 2010, the United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion to remand these claims to the Board. Thereafter, the Board remanded the claims for further evidentiary development in September 2010, December 2011, and February 2013. The requested development was completed and the claims have since been returned to the Board for further appellate consideration. Although the claims were originally characterized as claims for entitlement to service connection for PTSD and nerve problems, to include adjustment disorder and depression, the Veteran has also been diagnosed with other psychiatric conditions. To adequately reflect the claims, the issues have been amended accordingly. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In July 2013, the Veteran submitted additional evidence accompanied by a waiver of initial consideration by the RO. See 38 C.F.R. § 20.1304 (2012). A review of the Veteran's Virtual VA electronic claims file is negative for additional information or evidence pertinent to the claims on appeal. FINDINGS OF FACT 1. Resolving doubt in the Veteran's favor, the evidence demonstrates that he has a currently diagnosed major depressive disorder which has been related by a VA mental health professional to his in-service personal traumas, which are consistent with the circumstances of his service. 2. The evidence of record does not establish a diagnosis of current and chronic PTSD that is etiologically related to a stressful event during service. CONCLUSIONS OF LAW 1. The criteria for service connection for major depressive disorder have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304(f) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist In correspondence dated in May 2005, prior to the decision on appeal, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012), known as the Veterans Claims Assistance Act of 2000 (VCAA). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claims; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. Similar information was contained in a subsequent March 2013 letter. 38 C.F.R. § 3.159 was revised, effective May 30, 2008, removing the sentence in subsection (b)(1) stating that VA will request the claimant provide any evidence in the claimant's possession that pertains to the claim. Subsection (b)(3) was also added and notes that no duty to provide § 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established." See 73 Fed. Reg. 23,353-23,356 (Apr. 30, 2008). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "Court") in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. Additional notice as to this matter was provided in December 2007 and March 2013. Also, a November 2010 letter notified the Veteran of the information and evidence, to include alternative forms of evidence, to substantiate a claim for service connection for PTSD based on an in-service personal assault. Since the Veteran was provided with the most recent notice letter dated in March 2013, and after the Veteran and his representative were given an opportunity to respond, the claims for service connection for PTSD and an acquired psychiatric disorder were most recently readjudicated in a May 2013 supplemental statement of the case (SSOC). Hence, the Veteran is not shown to be prejudiced by the late timing of the aforementioned post adjudication notice letters. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). VA has done everything reasonably possible to assist the Veteran with respect to his claims for service connection in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). All identified and available service treatment and personnel records, post-service VA and private treatment records, and records obtained from the Social Security Administration have been secured. As noted above, the Board remanded this case for further development in September 2010, December 2011, and February 2013. In accordance with the September 2010 remand, the Veteran's complete service personnel records were obtained and associated with the claims file in June 2011; VA treatment records dating since August 2007 were obtained from relevant VA facilities and associated with the claims file, and; the claims were readjudicated in the September 2011 SSOC. In accordance with the December 2011 remand, the Veteran was afforded a VA psychiatric examination in January 2012, and the claims were readjudicated in the December 2012 SSOC. In accordance with the most recent February 2013 remand, the Veteran was provided with compliant VCAA notice containing the information and evidence necessary to substantiate his claims for service connection and he was requested to identify any relevant treatment received for the claimed psychiatric disabilities; he was provided with an additional VA psychiatric examination in May 2013, and; the claims were readjudicated in the May 2013 SSOC. Thus, there has been substantial compliance with its prior remand orders. See Stegall v. West, 11 Vet. App. 268 (1998) (duty to ensure compliance with Board remand order). Furthermore, the Veteran was afforded a VA examinations in January 2012 and March 2013 to determine the nature and etiology of any current psychiatric disabilities in connection with his claims for service connection for PTSD and an acquired psychiatric disability. Although the Board previously found the January 2012 VA examination to be inadequate for purposes of adjudication of the claims decided herein, for reasons expressed in more detail in the decision below, the Board now finds that the January 2012 and March 2013 VA examination reports, in combination and when considered with the other evidence of record, sufficiently address the Veteran's claims. The VA examiners reviewed the Veteran's past reported and documented psychiatric history, recorded his current complaints, conducted an appropriate interview and evaluation of the Veteran, and to the extent possible, rendered appropriate conclusions consistent with the remainder of the evidence of record. The Board, therefore, concludes that the examination reports, in combination and when considered with the other evidence of record, are adequate for purposes of rendering a decision with respect to the issues decided herein. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board acknowledges that in the June 2013 post-remand brief, the Veteran's representative contended that the May 2013 VA examiner's opinion is inadequate because (1) it did not contain any supporting rationale as to why the criteria for diagnosis of PTSD are not met, and (2) there is no indication that the Veteran's lay statements regarding his in-service personal assault stressor were considered. For reasons discussed in detail in the decision below, however, the Board disagrees with such contentions and finds that an additional remand for obtainment of a new examination or opinion is not necessary. Neither the Veteran nor his representative have identified any additional, relevant evidence that has not otherwise been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claims, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claims. Finally, the Veteran has declined the opportunity to present testimony in support of his claims. Thus, the duties to notify and assist have been met. II. Rules and Regulations The Veteran essentially contends that service connection is warranted for PTSD and an acquired psychiatric disorder due to traumatic experiences that occurred during his active military service. He has reported three specific stressors or in-service traumas to which his claimed psychiatric disabilities are related. First, he has reported that an East German Patrol Boat aimed its machine guns at him during his military service in Berlin, Germany. Second, he has reported an unreported altercation and subsequent racial tension with African American troops with conflicting reports of harassment and/or being physically assaulted by them during his three years of service in Germany. Finally, he reportedly awoke in the middle of the night during a training to find an African American male standing over him with a knife and knew that he was going to be stabbed. He asserts that his claimed stressors have resulted in a phobia of the general public and panic attacks where he feels like he does not belong and needs to fight back to escape the situation. He claims that h is unable to be around groups, individuals, and supervisors, and he has a constant fear of African Americans and fear of an attack, persecution, and retaliation. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Establishment of service connection for PTSD requires: (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); 38 C.F.R. § 4.125(a). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1). See also 38 U.S.C.A. § 1154(b). That is not the case here, so this will be discussed no further. If there is no combat experience, or if there is a determination that the Veteran engaged in combat but the claimed stressor is not related to such combat, there must be independent evidence to corroborate the Veteran's statement as to the occurrence of the claimed stressor. Doran v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. Cohen, 10 Vet. App. at 142, Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). The regulations pertaining to PTSD were (relatively) recently amended, and 38 C.F.R. §3.304(f)(3) no longer requires the verification of an in-service stressor if the Veteran's stressors involve "fear of hostile military or terrorist activity." Although one of the Veteran's claimed stressors included having a gun pointed at him by an East German patrol boat, given that the Veteran has not been diagnosed with PTSD at any time during the claim, it is not necessary to discuss this any further. III. Factual Background The Veteran's service records show that during his active military service, he was assigned to a light weapons infantry unit in Berlin, Germany from August 1963 to July 1966. His military occupational specialty during that time was gunner. He admittedly does not have combat service, nor are his service personnel records reflective of any military awards or decorations reflective of combat service. His service treatment and personnel records are negative for any indication that a psychiatric disorder had onset during his active military service. His service personnel records are negative for any evidence recognized by VA as indicating that physical assault or harassment may have occurred during service. Post-service VA treatment records and examination reports show that upon undergoing a VA general medical examination in October 1995, the Veteran's psychiatric status and personality were described as normal. During VA treatment in December 1998, the Veteran related a history of depression with prior suicidal ideations. In July 2001, a VA depression screen was positive. The Veteran reported current and a past history of depression. During an August 2001 VA comprehensive mental health evaluation, it was noted that the Veteran had been unemployed since 1995. He reported increased depression in the 4 years prior and he related his depression to the fact that he can not longer do what he used to. Diagnostic assessment was adjustment disorder with depression and alcohol abuse in remission. In January 2003, a VA depression screen was positive, however, the Veteran declined follow-up. He was asked about the years and locations of his military service and whether he experienced any military sexual trauma. There was no mention of his stressors as currently alleged at that time. In his April 2005 claim for service connection, the Veteran stated that he has "PTSD and nerve problems" directly associated with his military service. During a VA initial mental health consultation in September 2005, the Veteran felt that since getting older there is no reason to be around anymore. He complained of suicidal ideations since a few months prior, irritability, ongoing pain, sleep difficulty, an increased startle response, some hypervigilance with difficulty for a while after hearing a helicopter but he was unsure why it bothered him, nightmares about things that did not happen, and disliking being around people. Growing up, his father was very abusive to him and his mother. During service in Berlin, Germany, he became intoxicated and "got into a fight with a group of blacks" who subsequently harassed him throughout his three years of service there. He was made the scapegoat and was miserable. The group harassed him by hitting him in the back at chow. On discharge, he felt "messed up" so he lived on unemployment until he went broke. He would get jobs but would get mad and quit. He had a major problem with alcohol until he quit in 1992. Diagnostic assessments included depression and symptoms of PTSD from childhood reinforced by his army experience, chronic pain, and insomnia. In October 2005, a VA PTSD screen was negative. In August 2005, lay statements received from the Veterans friends of between 5 and 40 years indicated that the Veteran has PTSD related to his military service. They stated that his symptoms included nightmares about his military experiences resulting in an inability to sleep, panic attacks, suicidal ideations, and depression. In his December 2005 notice of disagreement, the Veteran stated that he does not get along with others due to issues from his "combat service." He related nightmares and depression with suicidal ideations to his military experiences. In December 2008, the Veteran reported a long history of chronic depression. He was sad most days and thought about his son who had passed away several years prior. Diagnostic assessment was depression. During an initial mental health consultation in December 2008 with a licensed clinical social worker, prior psychiatric treatment was denied. The Veteran complained of vivid memories of his service in Germany and being threatened with a knife and hit in the back by others. It was noted that he experienced a history of abuse during service and significant anger about it had worsened with age. It was also noted that he was seeking compensation. Diagnostic assessments were recurrent major depression and rule out psychosis. The social worker stated that the Veteran was obviously depressed with longstanding resentment toward conflict with peers during service. A mental health treatment session in January 2009 focused on "anxious ruminations as part of depression." The Veteran had periods where he could not stop thinking about his traumatic military experiences, to include an ongoing pattern of conflict with a group of soldiers and experiences where innocents from East Berlin were shot. His sense of suspiciousness towards others and self critical thoughts resulted in self isolation. A February 2009 VA primary care note stated that the Veteran has a long history of depression and PTSD related to memories of his experiences in Berlin and fear for his life by Soviet troops. Diagnostic assessment was anxiety. During a March 2009 mental health evaluation, the Veteran reported mood, anxiety, PTSD, and psychotic symptoms. He became anxious occasionally while sitting home alone and recalling incidents from his military service. He would ruminate about other troops who overdosed on alcohol to escape duty in Berlin and of being threatened by other troops in racial conflicts. He reported occasional nightmares but he forgot the content almost immediately. He reported a 40+ year history of regular auditory hallucinations of hearing voices call his name when alone, especially while in the woods. Diagnostic impressions were rule out PTSD and recurrent depression with psychosis, anxiety, and insomnia. In April 2009, the Veteran's VA mental health provider requested a psychiatric evaluation to determine whether the Veteran's symptoms meet the diagnostic criteria for PTSD. Per his own self-report, he did not serve in Vietnam or in a combat zone, nor was he exposed to combat conditions. His reported traumas included President Kennedy's assignation and racial tension in his unit. He reported involvement in a verbal altercation with African American troops and that he subsequently awoke one evening to find one standing over him with a knife. At first the Veteran stated that the man was trying to stab him, however, his story changed when asked why he was not hurt or why other soldiers did not intervene. Although fully oriented, his speech and thoughts were disorganized and his reported timelines and details were inconsistent. When questioned as to the specifics of his claimed stressor, the Veteran either attempted to change the subject or altered details. For example, when asked why he was not stabbed, he stated it was because he was in a sleeping bag and the man did not know it was him. He also stated that the sergeant felt sorry for him, but when asked why, the Veteran appeared confused and said that he did not know why. He stated that his supervisors never came in there (presumably meaning the barracks) because he guessed they were scared, too. He did not appear to be intentionally changing or fabricating his story. His thinking was disorganized but not bizarre. His expressed fear of African Americans had a delusional quality to it. For example, he said that he avoids going to restaurants because he is "afraid that guy will talk to some of his old friends and they will hurt me." When asked why he felt that way, he appeared confused and did not know. He stated that being harassed in the mess hall during service led to his fear of restaurants. A long history of alcohol abuse was noted and the Veteran reportedly quit 5 years prior because he was raising his two sons, however, he earlier stated that one of his sons died at age 30 in 2007 and his other son was 31. When reminded that his sons would have been in their 20's five years prior, he responded that he cannot do math and that he is unsure exactly when he stopped drinking. He was reportedly a heavy drinker during service and always drunk in the barracks. The psychologist reiterated that the Veteran did not appear to be purposely deceptive but rather confused. He appeared to be an inaccurate historian, thus, it was unclear how much of his reported history was accurate. The psychologist opined that the Veteran does not meet the criteria for diagnosis of PTSD based on his endorsed symptoms. Also, as there was question about his actual traumatic experiences, it was unclear and also unlikely that his experiences rose to the level of meeting the diagnostic criteria for PTSD. The psychologist opined that his symptoms appeared to be better accounted for by a diagnoses in the dementia sphere. Group PTSD treatment notes dating since 2009 show diagnoses of recurrent major depressive disorder, perhaps in partial remission, with anxious features. Thereafter, mental health treatment records show diagnosis of depression with psychosis, anxiety, and insomnia. During group PTSD treatment in February 2010, the Veteran shared about how his experiences led to not trusting others in terms of expecting them to turn on him and how it related to him being depressed. His expectation of being abused by others affected his ability to engage with others. He reported self hate related to not knowing what to do about others threatening him with a knife. In September 2010, he identified images of Russian gun boat and of guy standing over his bed with knife in the past with current feelings of being unacceptable when trying to approach crowds. In November 2010, it was noted that his over generalizing of his military experiences in Germany led to anxious avoidance of others. In a November 2010 statement, the Veteran's mother indicated that following the Veteran's discharge from military service, he moved away, got married, had children, and maintained what appeared to be a good marriage. He was divorced in 1992 at which time he moved in with her. He did not sleep much and he would not go out with family or come around much. Also, a statement received from NA, who had lived with the Veteran since 10 years prior, stated that the Veteran was threatened by people of color during service and that he avoids social settings most of the time. KZ, who has known the Veteran since childhood, stated that the Veteran had been self isolated and not the same since discharge. WMP, who has known the Veteran since prior to his military service, stated that he seemed bothered by life, did not sleep much due to nightmares related to his military service, and he shook and had a nervous problem. In a December 2011 statement, the Veteran's brother indicated that the Veteran talked about conflicts during service while home on leave. He stated that since discharge, the Veteran had been withdrawn from family and friends. In January 2012, the Veteran was afforded a VA psychiatric examination for diagnosis, to determine the nature and etiology of any current psychiatric disability, whether the evidence indicates that the claimed in-service physical assault occurred, and whether it was of a nature sufficient to meet the requirements for diagnosis of a psychiatric disability according to the DSM-IV. Pre-service psychiatric history was denied. As to his claimed stressors related to in-service physical assault(s), the Veteran denied being physically assaulted during service. He clarified that it was "not a fight. . . it was more like an argument," which occurred in or around 1963. He also awoke one night to a service member holding a knife over him in or around 1966. Another reported stressor was when a Russian patrol boat pulled a gun on him during maneuvers on the Rhine River. He began drinking during service even though it made him sick. He continued to drink heavily after service, up to 1 pint a day, until 1994. Following discharge, he attended college for 2 years with fairly good grades, however, he became frustrated and dropped out. His longest term of employment was for 8 years at a copper plant and for 5 years at a power plant. When someone would get mad at him he would walk off of the job. He was a poor historian regarding his employment history and it was difficult to obtain details. Sentinel events other that his claimed stressors included when his wife left him, which "really put [him] down." The January 2012 VA examiner noted that treatment records showed that psychiatric complaints were initially noted in 2000 when he had a depressed mood related to pain from injuries sustained in a 1975 motor vehicle accident. Diagnosis at that time was adjustment disorder with history of alcohol abuse. It was noted that the Veteran was seen in mental health three times between 2000 and 2001. In 2005, he complained of depression, traumatic reminders of military assault, chronic pain, and childhood abuse of he and his mother perpetrated by his father. Since December 2008, psychiatric diagnoses included major depression, anxiety, and insomnia. Significantly, while he had been attending PTSD group treatment, his treatment records were negative for a diagnosis of PTSD. During the January 2012 examination, the Veteran completed PCL-M, which is a subjective self-report assessment (without validity indicators) to assess the severity of PTSD symptomatology. He reported severe symptoms of PTSD with a total score of 82 out of a maximum 85. He also completed MMPI-2 , which has validity indicators for further assessment of his symptom severity and his approach to testing. His responses on MMPI-2 were indicative of an invalid profile and were suggestive of a "fake bad" profile. Given his response pattern, the examiner found that his approach was indicative of exaggeration of symptoms of a psychopathology or possible malingering. The examiner concluded that the MMPI-2 assessment resulted in an invalid protocol, thus, she was unable to render a mental health diagnosis, comment on level of impairment, or render an opinion regarding the possible stressor/s related to the Veteran's self-reported symptoms of PTSD. The claim was again remanded in February 2013 for an additional examination to determine the likely etiology of all currently diagnosed psychiatric disorders, to include PTSD, and for an opinion as to whether the evidence indicated that the claimed personal assault-related stressors actually occurred. Accordingly, the Veteran underwent an additional VA psychiatric examination in May 2013. The Veteran's claimed stressors included lining up outside of a truck by a Russian General, having a machine gun pointed at him by an East German patrol boat, and arguing with fellow soldiers who subsequently came looking for him with a knife. He did not actually see this happen, however, as he was hiding in a fellow-soldier's room. The Veteran reported a 30 year history of severe alcohol dependence, however, he quit in 1994. Sentinel events other that his claimed stressors included being left by his first wife in 1961 and by his second wife in the 1990s. Following a review of the claims file and interview and examination of the Veteran, the examiner opined that the claimed stressors, although stressful, do not represent what would be deemed a traumatic incident according to the DSM-IV. Specifically, she found that the Veteran had not been exposed to a traumatic event where he (1) witnessed, experienced, or was confronted with an event that involved actual or threatened death or serious injury or threat to the physical integrity of himself or others, and; (2) his response to the claimed stressor involved intense fear, helplessness, or horror. The examiner also concluded that that the Veteran's symptoms do not meet the diagnostic criteria for PTSD under the DSM-IV criteria. The examiner acknowledged that the Veteran had been diagnosed with depression and insomnia. She opined that the Veteran's current and only psychiatric diagnosis is depression with symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss. She further opined that his depression was less likely than not incurred in service or caused by his military service, to include his claimed stressors. She reasoned that while VA treatment records made it apparent that the Veteran's depression is chronic, and while the Veteran reported symptoms of depression since discharge, his service records are negative for any indication of a psychiatric disorder. Moreover, in 1998, the Veteran attributed his depression to a 1975 motor vehicle accident where he had to have extensive reconstructive surgery. In 2001, he indicated that his depression was related to medical issues. It was not until 2009 when he initially reported psychiatric complaints related to his claimed military stressors. In July 2013, the Veteran's VA mental health provider, a licensed clinical social worker, submitted a statement indicating that has been treating the Veteran for major depression with a rule out of psychosis since December 2008. As trust developed between he and the Veteran it quickly became apparent that the Veteran's true diagnosis is major depressive disorder with psychotic features. Since treatment began in 2008, the Veteran had been extremely isolated and suicidal through much of the treatment process. At the heart of his depression were experiences that occurred during his military service in Berlin where he was subject to having his life threatened as part of a racial conflict, which he viewed as evidence of a shameful failing of himself in terms of not being able to stand up for himself to the "black soldiers" and not being judged as worth protecting by his superiors. His shattered self-esteem led to choices of avoiding or running away from any conflict in his life, which had devastating effects vocationally and martially. While the Veteran had improved to the point of being stable in treatment, he experienced suicidal ideations at any attempt to reduce the intensity of treatment. The social worker stated that he could see why this would be hard to see by any examiner who only reviewed the records and interviewed the Veteran for one hour. As someone who has had the clinical process unfold over several years, however, he opined that it is clear that the Veteran's depression is directly connected to events that occurred during his service in Berlin. IV. Analysis Acquired psychiatric disorder other than PTSD Although the Veteran has provided conflicting information as to whether he was physically assaulted during service, the Board notes that there are special development procedures pertaining to the processing of a claim, for service connection for PTSD based on physical or sexual assault. See Patton v. West, 12 Vet. App. 272 (1999) (citing VA Adjudication Procedural Manual M21-1, Part III, paragraph 5.14(c) (Aug. 1, 2006)). Because personal assault is an extremely personal and sensitive issue, many incidents are not officially reported, which creates a proof problem with respect to the occurrence of the claimed stressor. In these situations, it is not unusual for there to be an absence of service records documenting the events the veteran has alleged. The victims of this type of trauma may not necessarily report the full circumstances of it for many years after it occurred. Thus, when a PTSD claim is based on a personal assault in service, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include, but are not limited to: records from law enforcement authorities; rape crisis centers; mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. 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. Id. Having considered all the evidence of record, and after resolving any doubt in the Veteran's favor, the Board finds that the Veteran indeed suffers from major depressive disorder with psychotic features, mild memory loss, insomnia, and anxiety as a result of racial tension during service and being assaulted or harassed during service. As such, service connection for major depressive disorder is warranted. The medical evidence outlined above clearly establishes that the Veteran has a longstanding and currently diagnosed acquired psychiatric disorder, which the most probative evidence establishes as being major depressive disorder. The Board acknowledges that there is no documentation of record confirming that the Veteran was harassed, mistreated, or threatened with a knife by African American troops as alleged. Additionally, the Veteran's service treatment and personnel records are negative for any evidence or indication that a psychiatric disorder had onset during service, nor is there any indication or evidence, such as poor performance evaluations or request for transfer from his duty station, suggesting that the claimed harassment and/or physical assault actually occurred. Nevertheless, the Veteran has consistently reported a history of alcohol abuse during service dating until the early 1990s. Moreover, lay statements received from the Veteran's brother and friends who knew him before and after service indicate that they observed behavior changes, such as being withdrawn from family and friends, immediately following the Veteran's discharge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (noting that a lay person is competent to report on that of which he or she has personal knowledge). This documentation is persuasive circumstantial evidence that is sufficient to enable to Board to concede that his claimed personal assault and harassment stressor occurred during service as alleged. As noted above, in a July 2013 statement, SH, the Veteran's treating VA mental health provider of approximately five years, opined that the Veteran's experiences during service where he was subject to having his life threatened as part of a racial conflict are at the heart of his currently diagnosed depression. SH reasoned that such experiences are perceived by the Veteran as a shameful failing of himself in terms of not being able to stick up for himself to the "black soldiers" and not being judged as worth protecting by his superiors. Such experiences resulted in a shattered self esteem, which led to subsequent choices involving avoiding or running from any conflict in his life, which had devastating effects occupationally and martially. As to the unfavorable May 2013 examiner's opinion, SH stated that it would be hard for any examiner who merely reviewed the record and interviewed the Veteran for an hour to see the relationship between the Veteran's depression and his military experiences. He stated that as someone who has built a trusting clinical relationship with the Veteran over a number of years and had the clinical process unfold during that time, it is clear that his depression is directly connected to events that occurred during his military service in Berlin. As for the unfavorable opinion provided by the May 2013 VA examiner as to whether the Veteran's currently diagnosed major depressive disorder is related to his claimed military traumas, the Board observes that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his or her knowledge and skill in analyzing the data, and his or her medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). As such, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical 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, 448-9 (2000). The Board finds the favorable conclusions reached in July 2013 statement of the Veteran's treating VA mental health provider to be the most probative of record. SH has treated the Veteran, who is admittedly untrusting of others, for his major depression for approximately five years. During that time, SH has been able to build a trusting clinical treatment relationship with the Veteran and become familiar with his presentation and psychiatric symptoms. Thus, the Board finds this opinion to be credible and probative. SH's opinion is based on his 5 years of clinical treatment of the Veteran for his major depression, his reported psychiatric history and current symptomatology, and appropriate diagnostic testing including PCL assessments on two or three occasions in October and December 2010. SH's July 2013 statement provides a definitive conclusion that is not speculative or conjectural in nature and his opinion is fully explained and consistent with the evidence of record. In sum, the Board concedes the occurrence of the Veteran's harassment and/or physical assaulted during his military service. Moreover, the Veteran has a current diagnosis of major depression related to those in-service events. Therefore, the evidence is at least in equipoise for the claim, and entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include major depressive disorder, is warranted. Thus, the claim is granted. In addition, the Board is cognizant that the Veteran's claim of entitlement to service connection for psychiatric disability encompasses all of his psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). In this regard, VA treatment records and examination reports show that psychotic features, mild memory loss, insomnia, and anxiety are all attributed to or symptoms of his major depressive disorder as opposed to separately diagnosed psychiatric disorders. Evidence in support of this conclusion is that findings of such psychiatric disorders on most occasions have been preceded by a diagnosis of "major depressive disorder with . . ." Although anxiety was a stand alone diagnosis by the Veteran's primary care physician, mental health providers consistently related anxiety and anxious ruminations to the Veteran's depression. PTSD In order to warrant service connection, the threshold requirement is competent medical evidence of the existence of the claimed disability nearly contemporaneous to or at some point during a veteran's appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim"); see also Romanowsky v. Shinseki, No. 11-3272 (Vet. App. July 10, 2013) (considering the application of McClain on a recent diagnosis predating the filing of a claim). Absent competent evidence of the existence of a disability, service connection cannot be granted. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). In this case, the most probative opinions of record specifically state that a diagnosis of PTSD was not conferred during psychiatric examinations and evaluations conducted throughout the claim. The evidence outlined above reflects that in April 2005, the Veteran himself claimed that he had PTSD related to military service. Similarly, lay statements received from his friends claimed that the Veteran has PTSD related to his military service. Although lay persons, such as the Veteran and his friends, are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case as to whether the Veteran's psychiatric symptoms and claimed stressors meet the diagnostic criteria for diagnosis of PTSD, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). There is no evidence suggesting, nor do the Veteran or his friends proclaim, to have education or training pertaining to psychiatric disorders. Following a mental health consultation in September 2005, the Veteran was found to experience symptoms (emphasis added) of PTSD from childhood which were said to be reinforced by his army experience. In October 2005, a VA PTSD screen was negative. A February 2009 VA primary care record noted that the Veteran "had a long history of . . . PTSD related to his experiences during military service and fear for his life by Soviet troops," however, this statement appears to be based on the Veteran's self-reported history of PTSD as opposed to a competent diagnosis of PTSD in conformance with VA regulations and the DSM criteria. Thus, it is assigned no probative weight in determining whether the Veteran has a current diagnosis of PTSD. A March 2009 mental health evaluation shows a diagnostic impression of rule out PTSD. A psychiatric consultation was performed by a psychiatrist in April 2009 for a determination as to whether the Veteran's symptoms meet the criteria for diagnosis of PTSD, however, the psychologist opined that the Veteran does not meet the criteria for diagnosis of PTSD based on his endorsed symptoms. She further found that as there was question about his actual traumatic experiences, it was unclear and also unlikely that his experiences rose to the level of meeting the criteria for diagnosis of PTSD. The psychiatrist opined that the Veteran's psychiatric symptoms appeared to be better accounted for by a diagnoses in the dementia sphere. The January 2012 VA examiner was unable to render a mental health diagnosis or and opinion regarding the possible stressor/s related to the Veteran's self-reported symptoms of PTSD. Nevertheless, she stated that it was significant that despite the Veteran's attendance in VA PTSD group treatment, the associated treatment records are negative for diagnosis of PTSD. Moreover, diagnostic testing at that time regarding the severity and validity of the Veteran's claimed PTSD, his responses were found to be suggestive of a "fake bad" profile. His response pattern was reflective of an approach indicative of exaggeration of symptoms of a psychopathology or possible malingering. During the May 2013 psychiatric examination, following a review of the claims file and interview and examination of the Veteran, the examiner opined that the claimed stressors, although stressful, do not represent what would be deemed a traumatic incident according to the DSM-IV. Specifically, she found that the Veteran had not been exposed to a traumatic event where he (1) witnessed, experienced, or was confronted with an event that involved actual or threatened death or serious injury or threat to the physical integrity of himself or others, and; (2) his response to the claimed stressor involved intense fear, helplessness, or horror. The examiner also concluded that that the Veteran's symptoms do not meet the diagnostic criteria for PTSD under the DSM-IV criteria. Finally, the July 2013 statement received from the Veteran's treating VA mental health provider of approximately five years is negative for any finding or diagnosis of PTSD. Having considered all the evidence of record, and after resolving any doubt in the Veteran's favor, the Board finds that the Veteran does not have a diagnosis of PTSD at any time during the claim or nearly contemporaneously thereto that may be related to his military service and his claimed stressors therein. The Board acknowledges the representative's contentions that the May 2013 opinion is inadequate because there is no indication that the Veteran's lay statements were considered, nor was supporting rationale provided for the conclusions therein. The Board disagrees. A review of the entire May 2013 examination report in its entirety shows that the Veteran's alleged stressors include being threatened with a knife, having a gun pointed at him by an East German patrol boat, and being lined up outside of a truck by a Russian General. During examination, contrary to the Veteran's prior reports about being threatened with a knife during service, the Veteran indicated that he did not actually see it happen because he was hiding in someone else's room. The examiner explained that this incident did not involve exposure to a traumatic event where he (1) witnessed, experienced, or was confronted (emphasis added) with an event that involved actual or threatened death or serious injury or threat to the physical integrity of himself or others, and; (2) his response to the claimed stressor involved intense fear, helplessness, or horror. The examiner also concluded that that the Veteran's psychiatric symptoms do not meet the diagnostic criteria for a diagnosis of PTSD under the DSM-IV criteria. In this regard, given the examiner's diagnostic assessment of major depressive disorder, the examiner presumably attributed the Veteran's psychiatric symptoms to that diagnosis. This is further buttressed by the examiner's notation that the Veteran had past diagnoses of depression and insomnia. Most significantly, the VA examiner's conclusion that the Veteran does not have PTSD is consistent with the most recent medical opinion of SH, the Veteran's own health care provider. As discussed, a July 2013 statement from SH indicates that he has treated the Veteran for major depression for approximately five years. During that time, SH has been able to build a trusting clinical treatment relationship with the Veteran and become familiar with his presentation and psychiatric symptoms. The Board has already found this opinion to be credible and probative in deciding to grant service connection for major depressive disorder as SH's opinion is based on his 5 years of clinical treatment of the Veteran, and the Board also finds it highly probative in determining that PTSD has not been present at any time during the pendency of this appeal. In light of the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of PTSD as a consequence of his claimed military stressors. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt rule does not apply, and the claim for service connection for PTSD must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for major depressive disorder with psychotic features is granted. Entitlement to service connection for PTSD is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs