Citation Nr: 1325148 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 10-23 027 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from July 1973 to October 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran testified before the undersigned Veterans Law Judge at a May 2013 videoconference hearing, and a transcript of this hearing is of record. FINDING OF FACT The Veteran's current acquired psychiatric disability is not related to a disease, injury or event in service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112 (West 2002 & Supp 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Service Connection 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, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) 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). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson v. West, 12 Vet. App. 247, 253 (lay evidence of in-service incurrence is sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). However, in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic by 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013). For disabilities that are not listed as chronic, the only avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). Psychoses is recognized as a chronic disease by 38 C.F.R. § 3.309(a). Certain chronic diseases, including psychoses, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2012). 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). In this case, the Veteran is seeking entitlement to service connection for an acquired psychiatric disability, to include PTSD, which he claims was caused by military sexual trauma. Establishing service connection for PTSD requires specific findings. These are (1) a current medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in- service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in- service stressor. See 38 C.F.R. § 3.304(f) (2012). The diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, of the American Psychiatric Association (DSM-IV). Id.; see also 38 C.F.R. § 4.125(a) (2012). 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). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat veterans); Gaines v. West, 11 Vet. App. 353 (1998) (Board must make a specific finding as to whether the veteran engaged in combat). The ordinary meaning of the phrase "engaged in combat with the enemy," as used in 38 U.S.C.A. § 1154(b), requires that a veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. VAOPGCPREC 12-99 (Oct. 18, 1999). Service in a combat zone does not establish that a veteran engaged in combat with the enemy. Id. Whether the veteran engaged in combat with the enemy is determined through the receipt of certain recognized military citations or other supportive evidence. West v. Brown, 7 Vet. App. 70 (1994). Previously, if VA determined either that the veteran did not engage in combat with the enemy or that the veteran did engage in combat, but that the alleged stressor was not combat related, the veteran's lay testimony, by itself, was not sufficient to establish the occurrence of the alleged stressor. Instead, the record had to contain credible supporting evidence that corroborates the veteran's testimony or statements. Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996). However, VA has recently amended its regulations governing service connection for PTSD by liberalizing the evidentiary standard for establishing the required in-service stressor where the following requirements are satisfied: First, the veteran must have experienced, witnessed, or have been confronted by an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance must have involved a psychological or psycho-physiological state of fear, helplessness, or horror. 75 Fed. Reg. 39852 (July 13, 2010) (codified at 38 C.F.R. § 3.304(f)). Second, a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor. Id. Additionally, there must be in the record no clear and convincing evidence to the contrary, and the claimed stressor must be consistent with the places, types, and circumstances of the veteran's service. Id. These revised regulations became effective July 13, 2010, and apply in cases which were appealed to the Board prior to July 13, 2010, but not decided by the Board as of that date. 75 Fed. Reg. 41092 (July 15, 2010) (codified at 38 C.F.R. § 3.304(f)). However, as the Veteran is not alleging PTSD due to combat with the enemy, these new regulations are not applicable. If PTSD is based on personal assault, as alleged in this case, evidence from sources other than the veteran's records may corroborate the occurrence of the stressor. 38 C.F.R. § 3.304(f)(3). Examples of such evidence include, but are not limited to: records from law enforcement authorities, mental health counseling centers, hospitals or physicians; and statements from family members, roommates, fellow service members, or clergy. Id. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in the mentioned 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. In Patton v. West, 12 Vet. App. 272, 277 (1999), the Court advised that the portions of the VA Adjudication Procedure Manual M21-1, Part III, paragraph 5.14c, provided "guidance on the types of evidence that may serve as 'credible supporting evidence' for establishing service connection of PTSD which allegedly was precipitated by a personal assault during military service." In December 2005, M21-1, Part III was rescinded and replaced with a new manual, M21-1MR, which contains the same PTSD-related information as M21-1, Part III. The corresponding new citation for M21-1, Part III, 5.14(c) is M21-1MR IV.ii.1.D.14 and 15. The aforementioned Manual lists evidence that might indicate occurrence of such a stressor, including lay statements describing episodes of depression; panic attacks or anxiety but no identifiable reasons for the episodes; visits to medical clinics without a specific ailment; evidence of substance abuse; and increased disregard for military or civilian authority. The Manual also lists behaviors such as requests for change of military occupational specialty (MOS) or duty assignment, increased use or abuse of leave, changes in performance and performance evaluations, increased use of over-the-counter medications, unexplained economic or social behavior changes, and breakup of a primary relationship as possibly indicative of a personal assault, provided that such changes occurred at the time of the incident. The Court has also held that the provisions in this Manual, which address PTSD claims based on personal assault, are substantive rules which are the equivalent of VA regulations, and are binding on VA. YR v. West, 11 Vet. App. 393, 398-99 (1998); Patton, 12 Vet. App. at 282. As noted above, the Veteran is seeking service connection for an acquired psychiatric disability which he alleges is due to military sexual trauma. The Veteran testified at his May 2013 videoconference hearing that approximately a month into basic training, he was raped by a group of his fellow service members. He has stated that he reported the assault to his frill sergeant, but that nothing was done. He has further claimed that he was seen by a military psychiatrist, to whom he also reported the rape, and was advised to seek a hardship discharge. However, the Veteran's service treatment records and service personnel records are negative for complaints of or treatment for any psychiatric problems, including any reported assault. The Veteran had a normal psychiatric examination at his separation from service in October 1973. Although the Veteran has claimed that he was seen by a psychiatrist in service and reported his rape, no such appointment is noted in his service treatment records and a search by the National Personnel Records Center for any inpatient psychiatric records was unsuccessful. Service personnel records show that the Veteran was discharged after only three months of service because [He] has proven himself to be a substandard soldier by his actions that include a very poor attitude, a total lack of motivation, and general poor performance. It is felt that an individual with these qualifications has no place within today's Army. [The Veteran] has been previously counseled.... While the Veteran has alleged that this poor attitude and lack of motivation can be attributed to his in-service assault, it is impossible to tell from the available service personnel records whether the Veteran's poor attitude and performance were present during his entire period of military service or began at a later date. Post service, the Veteran has been diagnosed with depression and anxiety disorder. Both VA and private medical records reflect conflicting explanations from the Veteran regarding the cause of his psychiatric complaints. At a January 2000 VA psychiatric consultation, the Veteran reported onset of depression in 1992 after becoming totally disabled because of physical disability. He reported that he received a hardship discharge from service because his adoptive father died and he needed to help his adoptive mother. An April 2000 VA treatment record notes a history of depression related to adjustment of job related issues and disability compensation. In May 2000, the Veteran reported stress related to the deaths of family members, as well as the denial of his claim for SSA disability benefits. A May 2001 VA outpatient treatment record notes that the Veteran is taking Prozac for depression and Trazodone for sleep, but that he presently has no significant symptom of depression. Significantly, at no time during his first few years of receiving psychiatric treatment at VA did the Veteran report a history of military sexual trauma. At a February 2002 Mental Status evaluation as part of his claim for SSA disability benefits, the Veteran again reported that he was discharged from military service because of family hardship. He reported that his symptoms began in 1973. It appears that the first time the Veteran reported being raped in service was in March 2008, at a VA psychology service consult. At that time, the Veteran reported that he was raped "by some Mexicans" during basic training at Fort Polk. He denied telling anyone about the rape, but claimed that he started to act strangely and was referred to a doctor for evaluation. He stated that he told the doctor nothing was wrong and was discharged. Following an April 2008 evaluation, the VA psychiatrist interviewing the Veteran described the Veteran's account of military sexual trauma as "sketchy", noting that story was told without emotional distress and the Veteran was unable to explain parts of his story that were illogical. He diagnosed the Veteran with a history of depressive disorder with no current clinical depression. He further concluded that the Veteran did not have PTSD or any signs of PTSD. He stated that the Veteran's story of PTSD symptoms is not consistent with the causation of PTSD. VA treatment records show that the Veteran has continued to report an incident of military sexual trauma to his VA mental health treatment providers. He has never been diagnosed with PTSD, but he has been diagnosed with depressive disorder, anxiety disorder, and rule out PTSD. None of the Veteran's treatment providers have attributed the Veteran's current acquired psychiatric disability to his military service, to include his in-service sexual assault. Based on all the above evidence, the Board finds that entitlement to service connection for an acquired psychiatric disability must be denied. There no evidence in the Veteran's service treatment records or service personnel records that the Veteran suffered from any psychiatric disability in service. Service treatment records and service personnel records are negative for any complaints of or treatment for psychiatric problems. Additionally, there is no evidence that the Veteran sought medical treatment in service without a specific ailment or that he requested a transfer or change in MOS. While service personnel records indicate that the Veteran displayed a poor attitude and poor performance, there is nothing in the contemporaneous records to suggest that the Veteran's behavior can be attributed to the alleged assault. Furthermore, over the years, the Veteran has offered numerous contradictory explanations for his psychiatric symptoms to his treatment providers and VA, some of which have nothing to do with the Veteran's military service. When the Veteran first began receiving mental health treatment from VA, he reported that his depressive symptoms began in 1992, and attributed his psychological distress to factors such as pain, physical disability, financial stressors, and the loss of family members. Only later did the Veteran claim he had been raped in service and even then his accounts of the incident have been contradictory. For example, in March 2008, the Veteran reported that he told no one about the rape. However, at his May 2013 hearing, he claimed that he reported the sexual assault to his superiors and to a doctor. The Veteran has also provided differing explanations for his discharge from service. In January 2001, he reported to a VA treatment provider that he had been discharged because his adoptive father died and he provided a similar explanation of family hardship at his February 2002 SSA Mental Status evaluation. However, he later began claiming that he was discharged because he was unable to function following his alleged in-service rape. Not only do these explanations contradict each other, they are also inconsistent with the Veteran's service personnel records, which attribute his discharge to unsatisfactory attitude and performance. These contradictions and inconsistencies undermine the credibility of the Veteran's statements as well as the probative value of the Veteran's testimony, and it is unclear which, if any, of the Veteran's statements are true. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). The Board finds that the Veteran is not credible and accordingly his lay testimony of an in-service sexual assault has little probative value. Furthermore, to the extent the Veteran has offered his opinion as to the etiology of any current acquired psychiatric disability, he has not demonstrated that he has any knowledge or training in determining the etiology of such conditions. In other words, he is a layman, not a medical expert. The Board recognizes that there is no bright line rule that laypersons are not competent to offer etiology opinions. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (rejecting the view that competent medical evidence is necessarily required when the determinative issue is medical diagnosis or etiology). Evidence, however, must be competent evidence in order to be weighed by the Board. Whether a layperson is competent to provide an opinion as to the etiology of a condition depends on the facts of the particular case. In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) drew support from Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) for support for its holding. Id. In a footnote in Jandreau, the Federal Circuit addressed whether a layperson could provide evidence regarding a diagnosis of a condition and explained that "[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran seeks to offer etiology opinions rather than provide diagnoses, the reasoning expressed in Jandreau is applicable. The Board finds that the question of whether the Veteran currently has an acquired psychiatric disability which is attributable to service is too complex to be addressed by a layperson. This connection or etiology is not amenable to observation alone. Rather it is common knowledge that such relationships are the subject of extensive research by scientific and medical professionals. Hence, the Veteran's opinion of the etiology of his current disability is not competent evidence and is entitled to low probative weight. As the Board has previously noted, there is no competent medical evidence establishing a relationship between the Veteran's current acquired psychiatric disabilities and his military service. Indeed, the medical evidence is against the Veteran's claim. In April 2000, the Veteran's treatment provider attributed the Veteran's depressive symptoms to his physical disability and financial problems. In April 2008, a VA psychiatrist described the Veteran's account of military sexual trauma as "sketchy" and inconsistent with the PTSD criteria. In other words, it does not appear that the Veteran has a current PTSD diagnosis. In light of the Veteran's lack of credibility and in the absence of either corroborating evidence of the Veteran's claims or a positive nexus opinion, the Board finds that entitlement to service connection for an acquired psychiatric disability, to include PTSD, must be denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the VCAA duty to notify was satisfied by a letter sent to the Veteran in January 2008. This letter informed the Veteran of what evidence was required to substantiate his claim, as well as of VA and the Veteran's respective duties for obtaining evidence. The Veteran was also informed of how VA assigns disability ratings and effective dates. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records. The Veteran submitted private medical records and records from the Social Security Administration (SSA), including a February 2002 psychological evaluation conducted as part of his claim for disability benefits. While the RO did not request records from SSA, the Veteran appeared to indicate at his May 2013 hearing that all relevant medical records have been obtained. Accordingly, the Board finds that no additional development is required. The Veteran was also provided an opportunity to set forth his contentions during the May 2013 videoconference hearing before the undersigned Veterans Law Judge. In this regard, the Board notes that in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010), the Court held that there are two duties imposed by 38 C.F.R. § 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked are not impacted by the Veteran's receipt of letter that complies with VA's duty to notify. In this case, during the Board hearing, testimony was elicited regarding the elements that were lacking to substantiate the claim and the Veteran and his representative demonstrated actual knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran's understood the criteria necessary to substantiate his claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Further, a review of the record also reveals no assertion, by the Veteran or his representative, that VA or the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any other prejudice in the conduct of the Board hearing. Accordingly, the Veteran is not shown to be prejudiced on this basis. The Board has considered whether the Veteran should be afforded a VA examination in connection with his claim for service connected benefits. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, the only evidence that the Veteran's acquired psychiatric disability is related to his military service is his own unsupported lay statements. Accordingly, the Board finds that referral for a VA medical examination is not warranted. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to service connection for an acquired psychiatric disability, to include PTSD, is denied. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs