Citation Nr: 1324655 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 05-33 285 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for psychiatric disability, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a back disability. ATTORNEY FOR THE BOARD Patricia Veresink, Associate Counsel INTRODUCTION The Veteran had active duty service from February 1971 to April 1972, including combat service in the Republic of Vietnam, and his decorations include the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The Board remanded the issue for further development in August 2007. When this matter was again before the Board in October 2009, the Board denied service connection for PTSD, an acquired psychiatric disability other than PTSD, and for a lumbar spine disorder. The veteran appealed the Board's October 2009 decision to the United States Court of Appeals for Veterans Claims (Court), which in an August 2010 order, granted the parties' joint motion for remand, vacating the Board's October 2009 decision and remanding the case for compliance with the terms of the joint motion, in which the parties agreed that remand to the Board was required to translate and consider the Veteran's April 2004 psychiatric evaluation conducted by Dr. Martinez. In the joint motion, the parties also agreed that the October 2008 medical opinion, on which the Board relied in their denial of service connection for back disability was insufficient as it was based on an inaccurate history. The Board found the Veteran to be credible in reporting the fall during service; however the examiner based his opinion in part on the lack of evidence of a fall during service. In August 2011, the Board again remanded this appeal. The Veteran's psychiatric evaluation was translated and considered in the determination of the claim. Additionally, the Veteran was provided with a VA examination in December 2011 with a subsequent addendum opinion in August 2012 regarding the Veteran's back disability claim. The examiner provided a nexus opinion based on an accurate history with a sufficient rationale for that opinion. Therefore, a review of the record indicates that the Board's directives were substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In April 2013, the Board requested the opinion of a medical specialist from the Veterans Health Administration (VHA). The requested opinion was received from a VHA specialist, which supports the Veteran's claim of service connection for psychiatric disability. The Board is proceeding with the adjudication of the Veteran's psychiatric disability claim without delay, i.e., foregoing providing a period of 60 days to offer evidence and argument in response to the VHA specialist's opinion because the VHA specialist's opinion is wholly positive and serves as abasis to grant service connection for PTSD, major depressive disorder, and alcohol dependence, which represents a complete grant of the benefit sought on appeal. Thus, the Veteran is not prejudiced. Further, the Board has recharacterized the psychiatric disability claims as set forth as a single issue on the title page. The Board acknowledges that the Veteran requested that his claim be advanced on the docket during the pendency of this appeal. The Board grants the Veteran's request to have his claim advanced on the Board's docket. 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 Veteran's PTSD, major depressive disorder, and alcohol dependence had their onset in service. 2. The preponderance of the evidence shows that the Veteran's back disability was not present in service or until many years thereafter and is not related to service or to an incident of service origin. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD with major depressive disorder and alcohol dependence have been met. 38 U.S.C.A. §§ 1110, 1154(a), (b), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The criteria for service connection for a back disability have not been met. 38 U.S.C.A. §§ 1110, 1154(a), (b), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The record shows that through VCAA letters dated December 2004 and August 2007, the Veteran was informed of the information and evidence necessary to substantiate the claims. The Veteran was also advised of the types of evidence VA would assist in obtaining, as well as the Veteran's own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. Further, the notice requirements apply to all five elements of a service connection claim: 1) veteran status, 2) existence of a disability, 3) a connection between the veteran's service and the disability, 4) degree of disability, and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA letter to the Veteran was provided in December 2004 prior to the initial unfavorable decision in May 2005. In this case, the Veteran was also advised of the criteria for rating a disability and those governing effective dates of awards in the August 2007 letter, prior to the most recent adjudication by the RO. The Board also finds that there has been compliance with the VCAA assistance provisions. The record in this case includes service treatment records, VA examination reports, VA treatment records, private treatment records, Social Security Administration records, and lay evidence. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case, and no further action is necessary. See generally 38 C.F.R. § 3.159(c). No additional pertinent evidence has been identified by the Veteran. The Veteran was afforded VA examinations in March 2005, October 2008, May 2009, December 2011, May 2012, and received an addendum opinion in August 2012 . 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board notes that the examiners were provided with an accurate history, the Veteran's history and complaints were recorded, and the examination reports set forth detailed examination findings. Therefore, the examination reports are adequate to decide the claims of service connection. Thus, further examination is not necessary regarding the issues on appeal. Service Connection - Laws and Regulations Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection - PTSD and Acquired Psychiatric Disability The Veteran claims that he currently has PTSD or an acquired psychiatric disability related to his active service. The Board acknowledges that the Veteran served in the Republic of Vietnam and received a Combat Infantryman Badge. The Board will address both PTSD and the acquired psychiatric disability other than PTSD together as they both stem from the same factual basis. The service treatment records are negative for diagnosis of psychiatric disability and on the Veteran's April 1972 report of medical examination, the Veteran was found to be psychiatrically normal. The Veteran received a private psychiatric examination in May 2000. The examiner provided a thorough mental examination, based on at least six separate interviews. The Veteran reported depressed thoughts, specifically about his inability to do what he used to do. The examiner diagnosed severe major depression and depressive disorder induced by medical condition, syndrome of carpal tunnel bilateral. In April 2004, the Veteran received a psychological assessment from another private examiner. The examiner noted that the Veteran participated in reconnaissance and infiltration missions that led him to stage frequent traumatic episodes and exposed him to action on a routine or daily basis. The Veteran informed the examiner that after his return from the warfront, his experiences continued to plague him, which led him to feeling extremely depressed, resulting in gradually deteriorating work and social performance. Because of all this, he sought professional help and left his job. The examiner provided numerous tests and results. The psychological evaluations reflect the Veteran's reports that the nature of his service led him to experience highly traumatic situations, which he still experiences despite the prolonged amount of time that has passed. The examiner noted that persons with schizophrenic disorder offer these profiles. Based on these test results, the examiner determined that the Veteran's mental condition is directly related to his traumatic experience during his service. A December 2004 stressor statement by the Veteran indicates that he was part of an ambush in a riverbank where a sergeant was shot in the head and died. He also saw seven soldiers destroyed by mortars. He went on two reconnaissance missions during which a separate group of five men did not return. He also reported mortar attacks on several occasions when stationed in Cam Ranh Base. The Veteran was afforded a VA examination in March 2005. At that time, the examiner noted a history of an undated evaluation done by Dr. Marchena with diagnoses of PTSD, major depression, and generalized anxiety disorder. The examiner noted that the Veteran did not describe any specific stressors. The prior psychiatric evaluation also provided only nonspecific stressors. The examiner determined that the Veteran did not meet the DSM-IV stressor criteria for PTSD and diagnosed an anxiety disorder, not otherwise specified. The Veteran was afforded another VA examination in October 2008. The examiner reviewed the Veteran's history and provided a thorough psychiatric examination. The examiner noted the Veteran's stressors, specifically the mortar attacks that injured seven soldiers. The examiner acknowledged that the Veteran stated other traumatic events, but the mortar attack was the one that affected him the most. The examiner noted that the Veteran met the DSM-IV stressor criteria for PTSD. The examiner, however, stated that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD and instead diagnosed the Veteran as having depressive disorder, not otherwise specified. In May 2009, the Veteran's record was sent for an evaluation to determine the etiology of his depressive disorder, which was not given during the October 2008 examination. The examiner opined that the Veteran's depressive disorder was not caused by or a result of service. The examiner reasoned that the Veteran stated his depressive symptomatology started in 1989 with the first psychiatric evaluation in 1999 and he was discharged from military service in 1972. The Veteran denied depressive symptoms after discharge and described marital, family, and social relationships as good, having many friends, and enjoying fishing as a hobby. The military stressors occurred 17 years prior and are not related to his depression. In May 2012, the Veteran again attended a VA examination. The examiner noted the Veteran's history, to include his combat experiences such as the mortar attack and several ambushes. Although the stressor was found to meet the criteria for a traumatic event, the Veteran did not meet the remainder of the criteria. The examiner found that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-IV criteria. The Veteran has a diagnosis of depressive disorder, not otherwise specified. The Veteran met the DSM-IV stressor criteria for PTSD; hwoever, the examiner indicated that he did not fulfill the symptom criteria for persistent re-experiencing of the traumatic event, the symptom criteria for persistent avoidance of the stimulus, and the symptom criteria for persistent hyperarousal. The trauma did not cause impairment in social or occupational functioning and there was no change in functional status or quality of life due to trauma exposure. The Veteran was gainfully employed until 1999 when he developed a back condition working in a factory and, due to the physical condition of low back pain, he developed depressive symptoms with no relationship whatsoever to his military service. A temporal relationship between the Veteran's neuropsychiatric condition and military service is not established. In August 2012, the claims folder was reviewed by a VA examiner. The examiner opined that the Veteran's mental disorder did not meet DSM-IV criteria for PTSD. The MMPI-2 does not have scales that measure PTSD and the scales that measure psychopathology are easily manipulated. The examiner noted that there are no paper and pencil tests that accurately measure PTSD. Due to the conflicting information of record, the Board sought clarification in the form of an expert VA medical opinion, which was provided by the Chief of Psychiatry & Deputy Director for Mental Health of VA Boston Healthcare System. The specialist noted diagnoses of PTSD, major depressive disorder, and alcohol dependence. The examiner addressed the October 2008 examination, noting that the examiner did not diagnose PTSD as the Veteran did not have the criteria for avoidance symptoms or functional impairment. The medical expert opined that there is clear evidence for the Veteran to have met the criteria for avoidance symptoms and ample evidence for the appellant to have demonstrated functional impairment as evidenced by his prior depressive symptoms and suicidality, substance abuse/dependence, and profound decompensation into a mixed depressive and anxiety state once his livelihood was impacted. He opined that it is extremely likely that the Veteran's psychiatric symptomatology is directly related to his combat experience and statedthat PTSD is often a chronic condition that is frequently complicated with mood symptoms such as depression, suicidality and substance abuse. The specialist explained that these co-occurring conditions are diagnosed separately when present. The examiner stated that while he had no further information about the precipitating factors for the Veteran's suicidal crisis in 1980, it is likely related to a depressive symptom burden. These symptoms may be a function of difficulty re-adjusting to civilian life after combat, a substance use disorder, PTSD, or other factors. It appears to be proximate evidence of functional impairment in the eight years after returning from Vietnam. The medical expert went on to note that the Veteran's evaluations have been variable in their comprehensiveness and examination of all data. Throughout the fluctuating course, various symptoms have been elucidated with rarely all of the necessary diagnostic symptomatology to confirm a PTSD diagnosis at any given time. When this has been the case, lesser anxiety disorder diagnoses have been made. Upon a comprehensive review of the Veteran's symptom burden over time, a diagnosis of PTSD can firmly be established. He also noted that it is clear from the multiple evaluations that the Veteran has suffered a chronic and recurrent mood disorder. As to whether this mood disorder was directly related to service, his primary diagnosis of PTSD, or other factors is open to debate. In considering the complexity and relationship between his illnesses , it is the expert's opinion that it is at least as likely as not that this mood disorder is related to his PTSD and therefore his military service in combat. He has met the full criteria for major depressive disorder, which preceded his physical disability, but was likely exacerbated by it. Regarding the Veteran's alcohol dependence, the expert noted that the diagnosis is only alluded to without a discussion of the symptoms, time course, duration, or complications related to a substance abuse disorder. If present, however, the examiner found it is likely to be related to the primary diagnosis of PTSD. The weight of the evidence demonstrates that the Veteran does currently have a diagnosis of PTSD, major depressive disorder, and when considering the benefit of the doubt, alcohol dependence. The Board notes that the expert examiner's opinion in December 2012 significantly clarifies the diagnoses and indicates a firm belief that the Veteran's PTSD, major depressive disorder, and alcohol dependence are causally related to his military service. The examiner had access to and thoroughly reviewed all of the Veteran's claims file, medical records, and lay statements. Based on these findings, the Board finds that the December 2012 positive nexus opinion is the most probative opinion of record. The Board acknowledges that the Veteran also had a diagnosis of an anxiety disorder during the period on appeal. The Board finds that the December 2012 expert opinion addresses the anxiety diagnosis as a symptom of PTSD, which was only diagnosed separately when the other manifestations of PTSD were not significantly displayed enough to apply a full PTSD diagnosis. Therefore, the Board considers anxiety to be a symptom of PTSD and not a separate diagnosis. In sum, the evidence shows that the Veteran's PTSD, major depressive disorder, and alcohol dependence manifested during service or is related to service. Accordingly, service connection for PTSD, major depressive disorder, and alcohol dependence is granted. Service Connection - Back Disability The Veteran's service treatment records are silent regarding any complaints, treatment, or diagnosis of a back disability. The April 1972 report of medical examination found the Veteran's spine and other musculoskeletal system to be clinically normal. The Veteran has asserted that he fell during service and injured his back. As the Veteran served in combat and it is reasonable that he may have fallen during service consistent with the circumstances, conditions, or hardships of his service, the Board accepts that such an injury did occur. However, based on the evidence of record, the Board finds that the Veteran's current low back disability is not related to his injury during service. The record contains a U.S.A.R. enlistment report of medical history dated October 1978. The Veteran denied any recurrent back pain. The corresponding report of medical examination again found the Veteran's spine and other musculoskeletal system to be clinically normal. Again in January 1982, a report of medical history showed no current or past reports of recurrent back pain. The January 1982 examiner found the Veteran's spine and other musculoskeletal system to be clinically normal. Post-service, the Veteran's private treatment records show a diagnosis of a herniated disc in March 1995. The Veteran was treated for progressive low back pain since that time. He was diagnosed with evidence of spasm and tenderness in the lumbosacral region. In October 2008, the Veteran was provided a VA examination. The examiner noted the Veteran's history of a fall during service, although the Veteran did not go to sick call because he did not consider it an event of major importance. He noted that he went to civilian doctors several years after service due to low back and cervical pain. The examiner diagnosed L4-L5 and L5-S1 herniated discs by MRI and CT scan, bilateral lumbar radiculopathy secondary to the herniated discs, cervical and lumbar radiculopathy by EMG, and C4-C5 board based protrusion, mildly narrowing the spinal canal and foramina bilaterally, and C5-C6 and C6-C7 protrusions, with mild to moderate narrowing of the central canal and both neural foramina by MRI of the cervical spine. The examiner noted no evidence of treatment due to a low back disorder up to several years after active service. The examiner noted that in the absence of a documented fall in service, absence of treatment due to a back disorder up to several years after service, it is his opinion that the current cervical and low back disabilities are not caused by or the result of the alleged fall in 1971. The examiner noted that the Veteran worked as an industrial mechanic for 20 years, which is a physically demanding job on his back area with a lot of bending, lifting, and squatting, which makes the Veteran prone to suffer from discogenic disease with back problems. As the October 2008 VA examiner based their opinion, in part, on the lack of evidence of a fall during service, the Veteran was afforded another VA examination in December 2011. The examiner noted diagnoses of lumbar degenerative disc disease, Lf-L5, L5-S1 herniated discs, and bilateral lumbar radiculopathy. The examiner noted that the Veteran reported a standing high fall while he was in active service in 1971 in Vietnam. The examiner reviewed the Veteran's claims file and performed a thorough physical examination. The examiner noted that service treatment records are silent for back complaints while in service, specifically during the period of 1971. He noted that service connection for back problems was claimed several years after being released from active service and that the Veteran sought medical care in the private sector for his back disorder several years after separation form service. The examiner opined that low back disorders are less likely as not caused by or the result of a fall reported by the Veteran in 1971 or by military service in general. The examiner noted evidence on record that he sought medical care for his back disorder many years after being released from service. The Veteran worked as an industrial mechanic for more than 20 years after being released from active service. This kind of job required a physically demanding job in his low back area, which makes the Veteran prone to suffer from discogenic disease. The nature and etiology of the low back disorder are more likely related to the normal aging process. VA requested an addendum opinion, which was provided in August 2012, to ensure that he examiner understood that the fall did actually happen although it was not reported. The examiner noted that although the Board has accepted for unknown reason that the Veteran had a fall during service, his lumbar condition is still less likely as not related to his fall in service. The Veteran did not claim service connection for a back problem for many years after being released from active service. The medical evidence is from twenty years and more after service. The Veteran worked as an industrial mechanic for more than 20 years after being released from active service. This kind of job required a physically demanding job in his low back area, which makes the Veteran prone to suffer from discogenic disease. The nature and etiology of the low back disorder (in this case) are more likely related to the normal aging process, especially in this Veteran who worked in a physically demanding job for more than twenty years. The examiner specifically stated that the lumbar condition is still less likely as not related to his fall in service. Assuming the Veteran had a fall in service, which caused back pain to the Veteran, there is no evidence of treatment for a back disability up to several years after discharge. The only evidence of record relating the Veteran's current back disability to his active service includes the Veteran's lay assertions that the disability is caused by his fall during service. The Veteran has not demonstrated that he has expertise in medical matters. While there is no bright line exclusionary rule that a lay person cannot provide opinion evidence as to a nexus between an in-service event and a current condition, not all medical questions lend themselves to lay opinion evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Here, although the Veteran is certainly competent to testify as to symptoms, the question as to the etiology of his back pain is a matter requiring medical expertise to determine. Indeed, a back disability can have multiple causes, and such question is one typically determined by persons with medical training. Thus, on this point, the Board finds the medical evidence of record to be more probative than the Veteran's lay assertion as to the cause of his back disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Here, there is no medical evidence of record that finds a relation between the Veteran's back disability and his fall during service. The only medical opinions in the file were provided by the VA examiners in October 2008, December 2011, and August 2012. Even acknowledging the Veteran's fall and current lay statements regarding back pain during service, the examiners found that the Veteran's current back disability is related to the natural aging process and his 20 years of work as an industrial mechanic. The examiners were fully informed of the pertinent factual premises of the case and addressed the Veteran's lay assertions, specifically, VA asked the August 2012 examiner to acknowledge that the Veteran's fall occurred during service consistent with his lay assertions of the event. The examiner then provided a fully articulated opinion that included a reasoned analysis. Therefore, the Board finds that the examiner's opinion is of significantly more probative value than the Veteran's lay assertions. In sum, the evidence does not show that the Veteran's back disability is related to service. Moreover, the most probative evidence indicates that the Veteran's back disability is related to the natural aging process and the demands of his profession. Accordingly, the preponderance of the evidence is against the claim, and service connection for a back disability is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for PTSD with major depressive disorder and alcohol dependence is granted. Service connection for a back disability is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs