Citation Nr: 1324199 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 09-15 620 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include a nervous disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran served on active duty from July 1969 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran appeared and testified at a Board hearing held by videoconference before a Veterans Law Judge (VLJ) in June 2011. A copy of the transcript of this hearing has been associated with the claims file. The Veteran's case was remanded by the Board for additional development in August 2011. After the matter was returned to the Board, the Veteran was informed in a February 2013 letter that the VLJ who conducted his hearing was no longer employed by the Board. The Veteran was offered an opportunity to testify at another hearing. See 38 C.F.R. § 20.707 (2012). The Veteran did not respond to the letter within the 30 days provided in the letter, nor has he since responded with a request for another hearing. Therefore, the Board finds that there is no hearing request pending at this time. See 38 C.F.R. § 20.702(e) (2012). Subsequent to the last supplemental statement of the case (SSOC), dated in June 2012, additional evidence was added to the claims file. In June 2013 the Veteran submitted private treatment records from April 2013 and a service personnel record. If an SOC or SSOC is prepared before the receipt of further evidence, an SSOC must be issued, as provided in 38 C.F.R. § 19.31 (2012), unless the additional evidence is duplicative or not relevant to the issue(s) on appeal. 38 C.F.R. § 19.37 (2012). In this case, the Board finds that the newly obtained evidence is not pertinent because the service personnel record was previously of record and is entirely duplicative. Moreover, while the April 2013 treatment records were not of record at the time of the June 2012 SSOC they are essentially duplicative in that they include duplicative and patently non-credible assertions as to the onset and course of the Veteran's psychiatric problems in service (such as stating, "I was a regular kid and then I was killing kids in the [V]ietnam war") and diagnoses based on these patently non-credible assertions. Therefore, the Board finds a Remand for RO consideration of the newly acquired evidence would serve no useful purpose. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the veteran are to be avoided); see also 38 C.F.R. § 19.31(b)(1). Finally, in April 2013, the Board referred the case to the Veterans Health Administration (VHA) for an expert opinion concerning the etiology of the Veteran's psychiatric disorder. See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901(d) (2012). The resulting June 2013 opinion has been included in the claims file for review. The Veteran and his accredited representative were notified of the VHA opinion in accordance with Thurber v. Brown, 5 Vet. App. 119 (1993). In response, a June 2013 letter from the Veteran's representative discussed the June 2013 opinion, stated that the evidence supported a grant of entitlement to service connection for the claimed benefit, and concluded, "Thus, without having further argument, the merits of his case have been advanced." The Board finds this statement evinced a clear intent for the Board to adjudicate the claim based on the evidence of record without further delay. FINDING OF FACT Clear and unmistakable evidence demonstrates that the Veteran's psychiatric disorder preexisted his active duty service, clear and unmistakable evidence demonstrates that the panic disorder with agoraphobia was not aggravated by service, and no other currently diagnosed psychiatric disorder is shown to be otherwise related to a disease, injury, or event in service. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for an acquired psychiatric disorder have not been met. 38 U.S.C.A. §§ 1101, 1111, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in January 2006 and August 2006 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letters informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. Since the Board has concluded that the preponderance of the evidence is against the claim for service connection, any questions as to the appropriate disability ratings or effective dates to be assigned are rendered moot, and no further notice is needed. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veteran Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of entitlement to service connection. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Records from the Social Security Administration (SSA) have been associated with the claims file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). In that regard, the Veteran was afforded a VA examination in August 2011. In addition, the Board sought a medical opinion through the Veterans Health Administration (VHA). The resulting June 2013 VHA medical opinion is of record. The Board finds the August 2011 VA opinion combined with the June 2013 VHA opinion report to be thorough and complete. The opinions expressed were based on the Veteran's reported history and review of the claims file. The opinions were supported by a complete rationale. Based on the opinions of record and the fact there is no rule as to how current an examination must be, the Board concludes the opinions in this case are adequate upon which to base a decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (finding that an adequate opinion is one that is based upon consideration of the Veteran's prior medical history and examinations, describes the disability in sufficient detail, and includes a conclusion supported by an analysis that the Board can consider and weigh against contrary opinions). Based on the August 2011 VA examination report and subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its August 2011 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). 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) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, 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). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In this case, the Veteran contends that the onset of his current psychiatric symptomatology occurred during his military service. The Veteran's service treatment records include his February 1969 Report of Medical History at the time of entrance into service, at which time he reported a history of "nervous trouble of any sort." The medical examiner at that time, noted that the Veteran had a history of being "nervous," but a contemporaneous psychiatric evaluation was found to be normal. In July 1969, the Veteran underwent a three day blood pressure check, which the Veteran contends is related to the onset of his psychiatric problems. In September 1969, the Veteran was seen on an emergency basis for complaints of nervousness and general somatic difficulties. At that time, he was afforded weekly group therapy and prescribed valium. The Veteran, however, failed to attend his first two scheduled group therapy appointments. A subsequent September 1969 treatment record noted known anxiety for which he had been prescribed valium. The Veteran requested a refill of the valium, noting symptomatic relief. In October 1969, the Veteran's valium prescription again was refilled, with the notation that the medication was working well without side effects. A November 1969 record indicated that the Veteran needed to be seen for psychiatric care and possible evaluation for generalized nervousness. The Veteran was seen and offered group therapy, which he accepted and attended several times. A December 1969 record noted the continued prescription of valium. The next relevant record was from April 1970, at which time the Veteran had failed to report for summer encampment and had called to state that he was emotionally disturbed and would be unable to perform his duties. The Veteran later that day was seen and displayed marked anxiety and appeared severely immature and unable to explain his reactions. On interview, the Veteran failed to demonstrate any psychotic symptoms or basis for his present condition. The Veteran indicated that he frequently became very nervous with marked and depressive symptoms and had been under psychiatric care for several weeks. The Veteran did not believe that the treatment had improved his symptoms. His reported past history demonstrated the need for mental health care during basic training. At that time, the Veteran was advised to return to the base in the future to attempt to return to full duty. The following day, however, the Veteran reported to sick call with acute anxiety and felt that he still was unable to perform his duties. He was markedly depressed with an anxiety overlay and a display of immaturity was paramount. Again, there were no psychotic symptoms. The Veteran was referred to a psychiatrist for evaluation and possible discharge and excused from summer camp. An August 1970 letter from a private psychiatrist indicated treatment of the Veteran in April and May 1970, with psychological testing completed in July 1970. The psychiatrist's opinion was that the Veteran suffered from schizophrenia, latent type, and that the Veteran had shown no motivation for treatment, as he had failed to keep his appointment in June 1970. In September 1970, the Veteran was found to be medically disqualified for service. A December 1981 private treatment record indicated reports that the Veteran had been disabled since September 1970, due to nerves, tension, and high blood pressure. The diagnosis was anxiety disorder, severe, chronic with depression. A September 1982 letter from the same treating psychiatrist indicated that the Veteran, "has never been able to hold a job." During a November 1982 Board hearing, the Veteran reported that he was treated for "nerves" as a senior in high school prior to military service. During this hearing, the one specific stressful incident discussed by the Veteran was being put on as crew chief of an aircraft with which he was not familiar. In August 2003, the Veteran was hospitalized for major depressive disorder. In November 2003, the Veteran was hospitalized for major depressive disorder and generalized anxiety disorder. In April 2004, the Veteran indicated that he first noted his depression and anxiety at age 22 (or approximately 1972) and that he had experienced problems with agoraphobia after the military, but that he was able to get over it with help. In May 2004, the Veteran was diagnosed with major depressive disorder, recurrent; panic disorder with agoraphobia; rule out alcohol abuse; and rule out generalized anxiety disorder. At that time, the Veteran reported that his brother experienced panic attacks. In February 2005, the Veteran was hospitalized for depression, shortly after losing his job. An April 2006 record included a diagnosis of anxiety due to medical condition. The Veteran was afforded a VA examination in August 2011. The examiner noted review of the claims file. At that time, the Veteran reported an "idyllic" childhood without anxiety. He claimed that on the second day of basic training he became very anxious and almost passed out. After three days of bed rest he was able to complete basic training. During Advanced Infantry Training (AIT) he experienced similar problems, starting on his second day. Thereafter, the Veteran was taken to a base hospital and prescribed Valium and group therapy. After AIT school, the Veteran returned to his home and was sent to monthly training in Ohio. Prior to one of these trainings, he got scared, drove to Pennsylvania, called the base, and was told to return. At that point, he was found not fit for duty. After examination, the examiner diagnosed panic disorder with agoraphobia and alcohol dependence in full remission and concluded that there was "no indication in the [claims file] of any incidents that occurred which would warrant the intensity of his reaction (such as life-threatening stressors); therefore it is less than likely that his diagnosis is related to his military service." Finally, in April 2013, the Board requested a VHA expert medical opinion. The resulting June 2013 medical opinion letter indicated review of the claims file. The opinion provider discussed the Veteran's psychiatric history. The examiner noted the past diagnoses of schizophrenia, but concluded that the Veteran did not have schizophrenia. The opinion provider expressed agreement with the August 2011 VA examiner's conclusions and noted that it "strains credulity" for the Veteran to contend that he was free of any mental health issues prior to his first day of basic training. The mere fact that the Veteran claimed that the sole stressor was the start of basic training demonstrated a preexisting tendency to develop panic symptoms, given that the first reported attack occurred only two days into basic training. Moreover, the Veteran has not identified a specific incident during basic training that could be considered a cause for aggravation of psychiatric problems. The opinion provider noted that the Veteran's father and brother were or potentially were alcoholics and that children from alcoholic households were more prone to panic attacks, depression, and other psychiatric problems. In addition, a May 2004 noted indicated that the Veteran's brother also experienced panic attacks. As such, the opinion provider concluded that it was not as likely as not that the psychiatric disorder was caused or aggravated by service. The rationale was based on the absence of specific military stressors and the family history of panic attacks. Instead, the Veteran had a preexisting condition that increased in severity over the ensuing decades due to the natural progression of the disease. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. The Veteran 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. VAOPGPREC 3-2003 (July 16, 2003); Jordan v. Principi, 17 Vet. App. 261 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). However, where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[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." 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2012). For Veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Initially, the Board notes that the Veteran's February 1969 medical examination at entrance into service did not indicate a current psychiatric disorder. As such, the Veteran will be presumed to have entered service in sound condition with respect to any psychiatric disorder. 38 U.S.C.A. §§ 1111 (West 2002); see also Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). As noted, however, the presumption can be rebutted by clear and unmistakable evidence. In this case, the evidence of record clearly establishes the Veteran's panic disorder with agoraphobia preexisted his military service. As noted above, the August 2011 VA examiner implicitly concluded that the Veteran's anxiety with agoraphobia preexisted his military service and explicitly found that it was less than likely related to service. The June 2013 VHA opinion provider specifically concluded that the Veteran's panic disorder preexisted his military service. Moreover, the Veteran reported a history of nervous trouble at the time of his entrance into service and during a November 1982 Board hearing stated that he was treated for "nerves" as a senior in high school prior to military service. The Board acknowledges that the Veteran now claims he did not experience psychiatric symptoms prior to entering service. Credibility, however, is an adjudicative and not a medical determination. The Board has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence. Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this case, the "inherent characteristics" of the Veteran's statements as to his psychiatric symptoms (or lack thereof) prior to service are inconsistent with the objective medical record and the Veteran's own contemporaneous statements. In that regard, as noted above, the Veteran reported a history of nervous troubles on entrance into service and in a more contemporaneous statement to his current contentions acknowledged that he was treated for "nerves" in high school prior to service. The Board finds these more contemporaneous statements of significantly greater probative value than his current statements denying pre-service psychiatric symptoms, made in the pursuit of VA compensation benefits. See Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that in weighing an applicant's credibility, the Board may consider any evidence of interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, and desire for monetary gain). Because of the consistent medical evidence of record, the Veteran's consistent contemporaneous statements reporting a history of nervous problems prior to service, and the lack of corroborating objective evidence, the Board finds that the Veteran's current denials of pre-service psychiatric symptoms have no probative value. The Board finds the history reported at entry into service and prior to pursuing his current claim for benefits based on the contention that his psychiatric symptom onset occurred in service to be far more credible than the history offered in support of a claim for benefits. As to the June 2013 VHA opinion, the Board acknowledges that the examiner noted that it was "debatable" as to whether the Veteran's panic disorder with agoraphobia preexisted service and, therefore, was not clear and unmistakable. The rationale for the notation was that the Veteran denied that he had any issues prior to service. As noted above, the Board has found those contentions to be less than credible. Moreover, the opinion provider also found the Veteran's contentions highly problematic, finding that any contention by the Veteran that he was free of mental health problems prior to military service "strains credulity in that it is self-serving and/or subject to recall bias." In light of the foregoing, while not using the term "clear and unmistakable," the Board finds that it is undebatable that the opinion provider's sole basis for refusing to use such language was the Veteran's non-credible contentions that he experienced no mental health problems prior to service. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293-294 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)). In summary, given how greatly the history offered by the Veteran during service and prior to the current claim contradicts the statements he has offered in support of this appeal and in light of the multiple medical professionals who concluded that the Veteran had a panic disorder that preexisted his military service, the Board finds that there is clear and unmistakable evidence of record that his panic disorder with agoraphobia preexisted service. See Doran v. Brown, 6 Vet. App. 283, 286 (1994). The Board notes that the presumption of soundness on entrance cannot be overcome simply based on the representations of the Veteran of a vague past history during the entrance examination or thereafter. See Miller v. West, 11 Vet. App. 345, 348 (1998) (holding that a veteran's self-report that he had previously suffered from "depression or excessive worry" prior to service was insufficient to rebut the presumption of soundness as was found in 38 U.S.C.A § 1111); see also Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In this case, however, as discussed above there is both probative clinical and lay evidence of the preexisting disorder, including the Veteran's acknowledgment that he received medical treatment for "nerves" prior to his entrance into service. As set forth in VAOPGCPREC 3-2003, the Board must also determine if there is clear and unmistakable evidence that the disorder was not aggravated during service. In this case, there is clear and unmistakable evidence establishing that the Veteran's panic disorder with agoraphobia was not aggravated by service beyond the natural progression of the disease. In this regard, the most credible in-service and post-service medical evidence of record clearly and unmistakably supports the conclusion that the Veteran's preexisting psychiatric problems were not permanently aggravated by his military service. In that regard, the Board finds the opinions expressed in the August 2011 VA examination report and the June 2013 VHA opinion of significant probative value. The opinions expressed were based on review of the claims file, in-service and post-service treatment records, and the Veteran's representations. Again, the August 2011 VA examiner and the June 2013 opinion provider did not use the term "clear and unmistakable," but in context it is evident that neither medical professional considered the Veteran's reported "stressors" to be sufficient to permanently aggravate his preexisting psychiatric disorder. The Board recognizes that the June 2013 opinion provider stated that it was "debatable" as to whether the preexisting psychiatric disorder was aggravated by service because, "It is possible that something might have happened that is not documented even though the Veteran does not specifically name it." That said, the Board notes that the Veteran has been provided multiple requests to set forth his in-service stressors and afforded numerous opportunities to set forth his contentions, yet he has not done so. As such, the Board does not find any basis to conclude that some unaddressed in-service stressor exists other than those set forth by the Veteran and rejected by both the August 2011 VA examiner and June 2013 VHA opinion provider as a sufficient basis for permanently aggravating the Veteran's preexisting psychiatric disorder. The reports otherwise provide a complete and thorough rationale for the opinions rendered and the conclusions reached are consistent with the credible evidence of record. As discussed above, while neither the August 2011 VA examination report nor the June 2013 VHA opinion use the term "clear and unmistakable" in their conclusions, read in context the Board concludes that both reports concluded that there was no basis of record to reasonably suggest that the Veteran's preexisting psychiatric disorder was permanently aggravated by his military service. Moreover, the mere manifestation of symptoms, such as periods of anxiety, does not demonstrate that the underlying psychiatric disorder underwent a permanent increase in severity in service. See generally Townsend v. Derwinski, 1 Vet. App. 408 (1991). The underlying disorder, as opposed to the symptoms, must be shown to have worsened in order to find aggravation. In this case, while the Veteran did seek treatment for nervous problems in service, the medical opinions of record have universally concluded that this treatment did not represent a permanent aggravation of the psychiatric disorder and that the stressors reported by the Veteran would be insufficient to result in a permanent aggravation of his preexisting psychiatric disorder. Thus, the evidence of record supports the conclusion that a permanent aggravation of a preexisting panic disorder with agoraphobia did not occur. See Jensen, 4 Vet. App. at 306-07; Green, 1 Vet. App. at 323; Hunt, 1 Vet. App. at 297. Thus, the only evidence that the Veteran's psychiatric problems began in or were otherwise permanently aggravated by service is his own lay assertions. As documented above, the Board does not find credible the Veteran's assertions that his psychiatric symptoms began in service. To the extent that the Veteran contends such symptoms permanently worsened due to service, the Board does not finds such representations of any probative value in light of the Veteran's lack of medical training and expertise and the complexity of attributing any observed symptomatology to a specific psychiatric disorder or to the permanent aggravation of that disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Therefore, in summary, the Board finds that the credible and probative evidence of record clearly and unmistakably shows that the Veteran's panic disorder with agoraphobia preexisted service and was not aggravated therein. For this reason, the Board finds that service connection for panic disorder with agoraphobia is denied. As to any other diagnosed psychiatric disorder, the evidence of record does not establish that such disability preexisted military service, had its onset in service or within one year of separation from service, or is otherwise related to service. In summary, the credible and probative evidence of record clearly and unmistakably establishes that the Veteran's panic disorder with agoraphobia preexisted service and was not aggravated by service. Furthermore, the preponderance of the evidence also shows that any other current psychiatric disorders were not incurred in or otherwise aggravated by his military service. Thus, the Board finds that the benefit of the doubt doctrine is not for application, and that the claim must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). ORDER Entitlement to service connection for an acquired psychiatric disorder, to include a nervous disorder, is denied. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs