Citation Nr: 1325484 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 95-18 781 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran had active military service from December 1990 to June 1991. He also served as a member of a reserve component with periods of active duty for training and inactive duty training. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a March 2000 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In that decision, the RO denied the Veteran's claim of service connection for posttraumatic stress disorder. The Board subsequently remanded the case multiple times, most recently in June 2012, for further notification, evidentiary development, and adjudication. In the June 2012 remand the Board noted that the Veteran had been diagnosed with and sought treatment for multiple acquired psychiatric disorders, including both PTSD and anxiety disorder. The Board thus characterized the issue as entitlement to service connection for an acquired psychiatric disorder, to include PTSD. Clemons v. Shinseki, 23 Vet. App. 1 (2009). FINDING OF FACT The Veteran does not have an acquired psychiatric disorder traceable to military service, including to any in-service stressor related to the Veteran's fear of hostile military or terrorist activity. CONCLUSION OF LAW The Veteran does not have a psychiatric disability that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000, during the pendency of this claim. See 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. 73 Fed. Reg. 23353 -56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. 38 C.F.R. § 3.159(b)(1). The Veteran's original claim for service connection for psychiatric disability was found to have been raised during hearing testimony in July 1995 before a hearing officer. Nevertheless, the Board finds that all notification and development action needed to arrive at a decision as to this claim has been accomplished. The Board finds that notice letters, dated in February 2002, April 2005, February 2006, August 2009, April 2011 and October 2011 satisfy the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In those letters, the Veteran was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. The Veteran was informed of the specific types of evidence he could submit, which would be pertinent to his claims, advised to send any medical reports that he had, and told that it was ultimately his responsibility to support the claim with appropriate evidence. The letters advised the Veteran of the information necessary to substantiate his claim, and the August 2009 letter notified him of the general criteria for assigning disability ratings and effective dates. Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Although the notice letters were not provided until after the RO initially adjudicated the Veteran's claim, the claim was properly re-adjudicated in May 2013, which followed the notice letters. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). Hence, the Board finds that the Veteran has received sufficient notice of the information and evidence needed to substantiate his claim, and has been afforded ample opportunity to submit such information and evidence. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claim. The Veteran's service medical records and Social Security Administration (SSA) records have been associated with the claims file, as have treatment records from the VA Medical Center (VAMC) in Pittsburgh, Pennsylvania (University Drive and Highland Drive facilities) and Banksville Road Family Medicine Associates. The Veteran has undergone VA examinations regarding his claims, the reports of which are associated with the claims file. Significantly, neither the Veteran nor his representative has otherwise alleged that there are any outstanding medical records relevant to the Veteran's claim that yet need to be obtained. VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Entitlement to service connection for PTSD requires medical evidence diagnosing PTSD in accordance with the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f) ; 4.125(a). Where the claimed stressor is not related to combat, the Veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the Veteran's account as to the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) ; 38 C.F.R. § 3.304(d), (f) (2012); Cohen v. Brown, 10 Vet. App. 128 (1997). Evidence denoting participation in combat includes award of decorations such as the Combat Action Ribbon, Combat Infantryman Badge (CIB), Purple Heart Medal, and decorations such as the Bronze Star Medal that have been awarded with a Combat "V" device. In this case, the Veteran's DD Form 214 shows that he did not receive any decorations or medals denoting participation in combat. Indeed, the Veteran has not claimed participation in combat. Where VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the veteran's account as to the occurrence of the claimed stressor. See 38 U.S.C.A. § 1154(b) ; 38 C.F.R. § 3.304(d), (f); Cohen v. Brown, 10 Vet. App. 128 (1997). With regards to the corroboration of stressors, the Board observes a recent amendment to 38 C.F.R. § 3.304 concerning stressors based on a veteran's "fear of hostile military or terrorist activity." Specifically, the amendment provides that, if a stressor claimed by a veteran is related to the veteran's "fear of hostile military or terrorist activity" and a VA or VA-contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor so long as there is not 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. Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39,843, 39,852 (July 13, 2010) (to be codified at 38 C.F.R. § 3.304(f)(3) ); 75 Fed. Reg. 41 ,092 (July 14, 2010) (correcting the effective date of the rule published on July 13, 2010). For purposes of this section, "fear of hostile military or terrorist activity" means that "a veteran experienced, witnessed, or was confronted with 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 involved a psychological or psycho-physiological state of fear, helplessness, or horror." 75 Fed. Reg. at 39,852. The Veteran contends that service connection is warranted for a psychiatric disorder, to include PTSD, related to his Gulf War service. He is noted to have served most of his overseas service in Egypt, staying one week in Saudi Arabia. His stressors have been reported by him in statements received in September 1998 and February 2002 to stem from incidents in service. The first incident was said to have taken place in January 1991 at an Egyptian Air Base, which he described as a secret air base that he and another person were assigned to guard in plain clothes and without weapons. He reported that, while parking along the Alexandria highway along the base, their vehicle was "boxed in" by 3 vehicles occupied by Arabs, who parked in front and behind them. He said that he saw the individuals appear to be going for their weapons, so they retreated and left the area. The second incident (which was described in September 1998, but omitted in February 2002), was described as having taken place in March 1991 when he was stationed at an outpost and captured 2 Arabs who were carrying small arms and detonators and trying to infiltrate the base, and he turned them over to an Egyptian security patrol who beat and then shot and killed the prisoners in front of him. He indicated that he did not tell any other Americans what happened because he did not want to get into trouble. He has also described a terrorist group began to attack tourists and police in Egypt in October 1992 (post service) including several places that he used to frequent. The Board notes that attempts to verify his claimed stressors yielded a response from the Joint Services Records Research Center (JSRRC) in January 2013 indicating that these 2 specific stressors related to his service at Cairo West Air Base and the Alexandria highway in Egypt could not be verified. However the JSRRC confirmed that the Veteran's unit was in Cairo Egypt in support of Operation Desert Storm, with duties of the Security Police to include security at a classified airport, and also indicated that in January 1991 heightened security measures were implemented including requiring service members to work 12-hour shifts. The VA RO in a March 2013 memorandum stated that although attempts at verifying the Veteran's stressor related to his service at Cairo Air Base had been unsuccessful, it determined that the Veteran's claimed fear of hostile military activity in the form of potential SCUD missile attacks was consistent with the time, place and circumstances of his service. Service treatment records reveal that on an enlistment physical for the National Guard, the Veteran had no disqualifying conditions and his report of medical history was negative for frequent trouble sleeping, depression/excess worry, loss of memory/amnesia, nervous trouble of any sort or loss of consciousness. Prior to activation he was assigned to 112th Security Police, and certified that he had no defect or disease that would disqualify him from active duty. Service treatment records from his period of active duty reveal no psychiatric treatment. At a July 1995 DRO hearing for other issues pertaining to Gulf War claims, the Veteran described difficulty sleeping including trouble staying asleep, waking in the middle of the night and nightmares, and he cited a couple of close calls to getting attacked. He described a lot of terrorist activity in the area he was in. He reported sleeping difficulties during that time and feared getting attacked in the middle of the night. He described anxiety not knowing what might happen. He denied any actual exposure to terrorist activities, but had nightmares in anticipation of such. This description was treated as a claim for service connection for PTSD. An August 1995 VA examination report for mental disorders described the Veteran as having been stationed in the Persian Gulf during the Gulf War, in both Saudi Arabia and Egypt. He remembered it as a terrifying experience and midway through the tour he became very sick to his stomach. Later he gained a lot of weight and had difficulty sleeping. He was feeling depressed, highly anxious and nervous. He reported that there was high terrorist activity in Egypt and they were always on the lookout for it. He indicated that the prime minister had been killed prior to his arrival and that there were terrorist attacks after he left. He described having issues having to adjust to stress since he returned home. He was noted to have recently graduated from the police academy and was working as a police officer. He said his symptoms were affecting his job and he was always tired. He was not able to sleep well and was feeling chronically anxious and nervous. He reported frequent nightmares, flashbacks and markedly enhanced startle reaction. He also endorsed hypervigilance. He only liked to associate with other Veterans and felt others could not relate. He had a restricted range of affect and flew off the handle easily. He denied drug or alcohol problems. He reported low energy levels and concentration problems. He denied suicidal or homicidal ideation. He admitted going through profound periods of depression and incapacitation and stated that he was in a lot better shape than before the Gulf War. Mental status examination revealed that he was neatly groomed, with no abnormal movements; his speech was coherent and not pressured. His mood and affect were somewhat depressed, particularly when talking about the Gulf. He had full range of affect and was not labile or anxious. His thought content and perception were absent of delusions, hallucinations or suicidal/homicidal thought. He was alert and oriented and had no focal deficits elicited. He was diagnosed with PTSD and major depressive episode (nonpsychotic). The examiner summarized the Veteran as suffering from PTSD with a coexistent major depressive disorder. In view of his circumstances, the examiner anticipated severe difficulties in occupational and social functioning. Plans included referral to a mental health clinic for further treatment. A June 1998 VA Gulf War disorders examination focused on physical complaints, but the Veteran was noted to not appear to have any acute psychiatric issues on examination. The report of a September 1998 VA examination included review of the claims file and again his Gulf War service with one week in Saudi Arabia and the rest of his tour in Egypt was noted. He described being stationed at a secret Airbase in Egypt and worked as a security policeman. He described 2 traumatic events. First was while in security, he served in plain clothes without weapons with a fellow service member. Two vehicles occupied by Arabs pulled next to them and they looked as though they would pull weapons on the Veteran's vehicle so they got out of there. He admitted they were not fired at but felt helpless as they were unarmed. The second incident was during a solitary shift, he caught 2 Arabs trying to infiltrate the base and handed them over to the Egyptians who shot the individuals in front of him. He indicated that he did not report this incident because he thought he might get in trouble. In addition to these events he described a constant feeling of fear and panic because he did not know if their base was going to be attacked. He denied any other combat-related experiences that he considered stressful. He indicated he talked a few times to a chaplain but did not recall mentioning any problems to him. He reported having psychiatric or psychological treatment a number of times after service, including by a Dr. Massario in July 1991, September 1996 and February 1998 for trouble sleeping and nightmares of the enemy. He also reported treatment in March 1998 for alcoholism. He reported that he worked as a police officer and indicated that he went to alcohol rehabilitation to avoid getting fired for an infraction. He described having been put on desk duty after threatening a supervisor who was dating his former girlfriend and of filing several grievances against supervisors he thought were harming him. Prior to entering rehabilitation, he drank heavily, which he described as beginning in Egypt. He denied illicit drug use. He was noted to have improved motivation since he quit drinking. He was married with one daughter. His subjective complaints included nightmares twice a week but otherwise no sleep problems, sleeping 6 hours a night with no trouble falling asleep. He reported low energy and feeling fatigued at times. He also felt depressed at times, particularly when thinking about the war. He also had some nervousness and anxiety. Sometimes he had "panic attacks" a couple times a week with physical symptoms including heart beating fast and he cited getting "paranoid" about getting fired. He could watch war movies although the movie "Private Ryan" made him depressed. He indicated that hearing a car backfire and eating middle eastern food reminded him of Egypt. He reported difficulty controlling his temper, especially when drinking. He was close to some coworkers and to his wife and daughter. He had a history of memory problems that resolved after he stopped drinking. Mental status examination revealed he was alert and oriented with a mildly restricted affect, and he appeared mildly anxious. His grooming and hygiene were excellent, and he spoke softly with communication goal-directed, relevant and coherent. He had no evidence of a formal thought disorder. He reported periodic symptoms of anxiety that he called "panic attacks." These symptoms did not meet the criteria for the DSM IV criteria for panic attacks. There was no evidence of agoraphobia. He had periodic feelings of depression present but no tearfulness noted on evaluation. He reported some anger outburst problems but his behavior was well controlled in his current evaluation. He had some mild sleep disruption, but got enough sleep. The Axis I diagnosis was alcohol dependence in early remission and depressive disorder not otherwise specified (NOS), possibly related to alcohol dependence. The examiner summarized the Veteran as having reported a number of symptoms consistent with PTSD but he did not meet the full criteria for PTSD. Also, before such diagnosis could be made, verification of his stressors was needed. Based on his information he was drinking heavily and had a number of work-related stressors that exacerbated or contributed to feelings of anxiety and depression. It appeared that with treatment of alcoholism, many of these symptoms had resolved. He also experienced some anxiety related to his Persian Gulf service, but these feelings of anxiety and depression would probably improve as his length of abstinence increased and he continued to work with supervisors to resolve his work conflicts. VA records from March 1999 addressing follow-up by neurology of his complaints of chronic fatigue noted a history that included PTSD, and noted the Veteran to seem depressed and mildly anxious on physical examination. He continued to complain of fatigue but did not feel overtly depressed. He reported some memory problems. He was assessed with chronic fatigue that might be indicative of dysthymia and depression and may be related to PTSD. Plans for psychiatry to evaluate him were made. An April 1999 psychology evaluation for treatment purposes noted the Veteran's history of psychological treatment, including the substance abuse treatment in March 1998 and the VA examinations of September 1998, and other treatment records that showed PTSD symptomatology reported as a result of his experiences in Cairo, Egypt. His childhood history was again described as normal although strict. He cited a normal high school and college history, relating that he enrolled in the ROTC program and eventually joined the Air National Guard wherein he was activated for Desert Storm. He described the history of being sent to Saudi Arabia and reassigned to Egypt where he reported guarding a secret air base. He described problems after his arrival, including getting sick after receiving vaccinations, and drinking heavily, becoming intoxicated nightly. He reported "terrorist activity" throughout Egypt, including an attack on tourists on his first day there. He also claimed that shots were fired at the base on six occasions. However, these happened usually at night and he was never directly involved. He again cited the same two traumatic events that he had cited in the September 1998 VA examination--being "boxed in" by two vehicles that he perceived as threatening, and witnessing the execution of two individuals he had captured and turned over to Egyptian authorities. He indicated he did not inform his superiors about this incident. His post-military history was noted to be significant for attending the police academy and joining the police force. While with the police, he reported that he had a motor vehicle accident 3 months into training, when he was accidentally "run over" by the police car when it started drifting backwards and dragged him a few feet. He also described his police work as including a 4-year assignment on patrol duty, which was stressful and included frequently seeing homicides, stabbings and shootings. He also indicated he drew his weapon several times but never shot anyone. He was reassigned to a walking beat in 1996 where he witnessed more homicides. He reported having problems with his job since coming home from Egypt and described being overweight and having a drinking problem that developed overseas. He also described work conflicts and interpersonal difficulties with partners and supervisors and described being harassed and falsely accused of misconduct. He indicated that an attempt to terminate him on what he deemed was a false accusation of impropriety resulted in his filing an action against the department after he attended a rehabilitation program. He was noted to be married since 1996 the same year he met his wife, and described the relationship as positive, although they had some financial challenges and some past problems when he was using alcohol. His subjective complaints included nightmares, flashbacks and panic attacks. However he denied being awakened throughout the night. He reported flashbacks during the shooting 1-2 times a month. He also described them as being triggered by reminders such as a car backfire or smells that resemble the desert. He also described "panic attacks" with physical manifestations such as chest pain, stomach discomfort and rapid heart rate. He also reported numerous dysphoric symptoms including feeling negative about his job and life, being irritable, withdrawn from others, decreased energy and fatigue and feeling sluggish. He had sleep disturbance but this was due to an irregular work schedule. He slept 6 hours a night. He denied suicidal ideations but did endorse homicidal thoughts particularly during conflicts with his superiors. He reported that he always carried a gun. Objective findings revealed appropriate dress and grooming, with clear sensorium and goal-directed speech, although he was rather vague during the interview. He was noted to have a flat affect, and his mood was somewhat depressed and down. He reported sleep difficulties with nightmares and a history of alcoholism with inpatient treatment. He had no evidence of a thought disorder or psychosis. He denied current suicidal or homicidal thoughts. His judgment and insight appeared to be poor. Overall he appeared dysphoric due to his current situation; however, he did not appear to have PTSD related to his Desert Storm experiences particularly since he did not report symptomatology other than "flashbacks, nightmares and panic attacks." Psychological testing was administered but he was unable to complete all testing due to a schedule conflict. The Axis I diagnosis was adjustment disorder with mixed anxiety and depressed mood, alcohol dependence in sustained full remission, major depressive disorder, recurrent, moderate, dysthymic disorder and factitious disorder with combined psychological and physical signs and symptoms. The psychologist in the April 1999 evaluation stated that the Veteran was not a likely candidate for enrollment in PTSD treatment because results of the evaluation indicated that he did not meet the criteria for PTSD. His reported exposures were noted to be virtually impossible to verify, given the "secret" nature of his position in the Gulf and his lack of notification to superiors. Moreover he did not report sufficient PTSD symptomatology to meet the criteria for this diagnosis. The psychologist further stated that the Veteran's overall interest in treatment was questionable, given that he had admitted that he was more concerned about his claim than treatment when asked in weekly therapy meetings. His symptoms were also noted to have coincided with his return to work and may be more related to chronic job satisfaction and a reportedly stressful work environment. Additionally, his financial difficulties, pending claims for service connection and against the city may constitute secondary gains that work to keep him in a passive victimized role. These secondary gains may also be an issue in his search for documentation of combat-related difficulties. Private treatment records include an October 2000 letter from Dr. Delaney stating that the Veteran had been under his care since July 2000 for stress related disorder treated with Zoloft daily. Additionally a September 2001 record showed that he underwent psychological testing with scores interpreted as showing his scores on the Inconsistent Response scale indicated he did not respond in a manner consistent across all scales, which may indicate he is suffering from a reduced attention span. His score on the Intrusive Experience Scale was interpreted as suggesting that he was suffering from intensive PTSD reactions and symptoms, including flashbacks, nightmares, upsetting memories triggered by current events and repetitive thoughts of unpleasant past experience. His trauma symptoms Inventory scores suggested that he was currently suffering from PTSD. In April 2003, the Veteran was seen by private psychologist Delaney for reevaluation of his status, with a history of having been evaluated in September 2000 for PTSD symptoms when he was a combat solder in the Gulf War in 1991. At that time he had difficulties with night terrors and general anxiety problems and marital difficulties. He was noted to have worked as a police officer, with PTSD symptoms reportedly affecting his job. His treatment history was said to include treatment in 1995 by the VA and had improved with prescription of SSRI's and having seen this provider 4 times between July and September 2000. At the time of this evaluation the Veteran was found to be anxious, tense and reported flashbacks as he had in 2000. He seemed to show signs of a rather major depression and had difficulty concentrating. There was no evidence of psychotic or paranoid behavior. All his symptoms were deemed consistent with the diagnosis of PTSD, and major depressive disorder (MDD). It was noted that the Veteran did not seek treatment, but rather evaluation, and it was suggested that he reestablish treatment with SSRI antidepressant to control his anxiety and MDD. The rest of the report focused on advising that he should not be employed as a police officer. A November 2003 private evaluation by Dr. Webb, MD, indicated that the Veteran consulted him for an independent psychiatric review. The review included records provided by the Veteran and a 11/2 hour interview and mental status evaluation. Following the evaluation, the diagnosis of Axis I PTSD and MDD was given, with these disorders said to be more likely than not directly related to the Veteran's military experience. Dr. Webb considered the Veteran to be a reliable historian, as his history was consistent with that given to other medical providers. The examiner recited findings from prior examinations and records and noted the Veteran's history included no signs of addiction or serious abuse prior to service, just binge drinking, but suggested that drinking with his military buddies led to alcoholism. The Veteran reported that alcohol was plentiful in Egypt. He said he was consistently aware of the potential for sudden death due to terrorism, which caused insomnia and automatic arousal and put him in a state of heightened awareness. The 2 incidents of trauma, the capture of 2 enemy soldiers who were killed after he handed them to Egyptians and the encounter of the vehicles filled with Middle Easterners that he felt threatened by were recited. He endorsed symptoms of irritable mood, insomnia, nightmares, early morning awakening and an "empty feeling" or ennui. He indicated that family/spouse conflict increased drinking and conflicts at work. The history of his work troubles with firing was noted. He was noted to describe flashbacks prior to termination. His treatment history was said to date back to 1991, with a diagnosis of PTSD made by the VA in 1995, and personality testing in 2001 noted to also be suggestive of PTSD. The Veteran currently was said to have panic attacks twice a week, with symptoms including excessive sweating, increased heart rate and rapid breathing. Dr. Webb opined that such symptoms should be classified as flashbacks as he did imagine himself back in Egypt reliving his experiences. The general hopelessness experienced in Egypt continued. He was mistrustful of others and continued with insomnia. Mental status examination was significant for succinct speech, poor eye contact, and irritable mood, although he tried to hide this. He had no homicidal or suicidal ideations. He seemed suspicious about the interview. He denied paranoid ideation but had ideas of reference, thinking that strangers might be talking about him. He appeared quite obsessed with trauma in Egypt. He had no hallucinations or delusions. His judgment, memory, and cognition were intact. He was diagnosed with PTSD, major depressive episode with panic disorder, as well as alcohol abuse, episodic. A February2004 VA examination for PTSD again noted the Veteran's Gulf War job was to guard an apparently secret airbase. He was in Cairo but was part of the 112th Tactical Fighter Unit. He indicated that there were terrorist attacks in Cairo while he was there, though he was neither a victim nor a witness of any. He again related the story of being "boxed in" by suspicious vehicles while he was unarmed, with no verification. He again related having arrested 2 "Palestinians" who had guns and explosives and turned them over to the Egyptians who executed them 25 yards away. He also claimed the base was fired on a few times, but there was no direct combat. His symptoms included nightmares about these incidents 2-3 times a week, trouble concentrating, being unable to feel comfortable and difficulty with overwhelming stress. He had multiple situational stressors and reported being recently fired from his police job and being convicted of perjury. He also indicated he lost his wife because of these issues. Again the history of alcohol dependence treated in 1998 was noted. He indicated that he resumed drinking in 2000 at the time of the divorce and claimed to be sober 6 months. He had no income and lived with his parents. He was facing possible jail time. These situational stressors as well as the fact that he was a police officer for 12 years and saw horrendous things and experienced many terrifying incidents in that capacity were considered far more relevant to his current mental status than anything that occurred in Cairo 14 years ago. He had no formal history of psychiatric treatment. He was noted to have been diagnosed in 1995 with PTSD, but this report was noted to be very short and quite incomplete, and did not outline any of his stressors or his symptom presentation. The 1995 report also was noted to have given no rationale for the diagnosis of PTSD. The examiner noted that more complete examinations were done in 1999 by 2 separate practitioners, neither of whom felt the Veteran had PTSD symptoms. Diagnoses of alcohol dependence and adjustment disorder were noted. The Veteran's reported history of having seen a group of local practitioners and psychiatrists and psychologists in 2003 was noted, with the purpose of obtaining opinions to bolster his claim for stress-related disability from the Police Department. This examiner, noted a perjury charge and noted that the medical professionals seen in 2003 were seen only for forensic purposes. The Veteran was noted to not currently be in psychiatric treatment, nor had he ever taken psychotropic medications for an extended period of time. He was noted to have participated in alcohol rehabilitation in a private facility. Psychiatric testing done by the examiner in February 2004 yielded scores inconsistent with his clinical presentation. This presented an exaggeration of symptoms, with similar findings of symptom exaggeration shown in prior test scores. His scores of severe depression were also found inconsistent with his clinical presentation, and also was said to represent symptom exaggeration. Mental status examination revealed he was alert, oriented and had good contact with reality. He had no symptoms of psychosis and spoke normally. He appeared significantly distressed although he presented in a reasonably calm and controlled manner. He was in a tough situation in light of his job loss, his wife, and possible loss of freedom as a result of a felony. He was under great stress and financially strapped. His affect was responsive but somewhat sluggish. He had no evidence of suicidal ideations and memory and intellect were intact. The impression by the February 2004 VA examiner following review of the claims file and examination was that the Veteran exhibited diagnoses of adjustment disorder with depressed mood secondary to life stressors unrelated to service. He also had alcohol dependence in short term remission. The examiner concluded that the Veteran did not meet the diagnostic criteria for PTSD either in terms of identified stressors or in terms of symptom presentation. Although the 1995 examiner had diagnosed PTSD it was felt that there was no indication that that examiner gave a rationale for the diagnosis and also did not provide any delineation of stressors or symptom pattern necessary to support a PTSD diagnosis. Thus, the 1995 examination was viewed as not providing a valid or extensive examination; nor did it contain any rationale for the diagnostic conclusions. Subsequent examinations were noted to consistently indicate that the diagnostic criteria for PTSD were not met. Additionally the Veteran secured employment as a police offer and maintained this until fired for felony charges, which was something that would be extremely difficult for someone suffering from PTSD. Undated VA records reveal that the Veteran was 37 years old and diagnosed with an adjustment disorder and alcohol dependence, with plans to schedule an appointment for treatment. Electronic notations indicate that he received treatment from January 2004 to December 2005 for problems that included alcohol dependence, anxiety reaction with anxious mood and alcohol abuse in remission. Also in 2005 the Veteran was incarcerated with health records from the Federal Correctional Facility showing on new intake in January 2005 that he had a history of depression noted, for which he was taking Celexa. He continued to be assessed with depression in February 2005 as a new arrival. Another record from February 2005 indicated that he was taking Prozac with moderate relief, and noted that jets in the area caused some flashbacks. Records from May 2005 and June 2005 showed PTSD and depression. A July 2005 record noted that he had been diagnosed by mental health professionals with PTSD secondary to Gulf War experiences, and noted that a change in medication from Zoloft to Prozac on arrival at prison caused nightmares and panic attacks. He was started on another medication, Remeron and had mild nightmares and stable mood. He was assessed with PTSD by history, in remission. A March 2006 private psychiatric evaluation by Dr. Webb summarized the Veteran as being disabled from employment and noted that he first evaluated the Veteran in April 2003 at which time the Veteran had sought disability alleging his middle East experience caused PTSD, panic attacks, recurrent MDD and made alcohol abuse worse. This evaluator noted that other doctors who examined the Veteran also agreed with the diagnosis of PTSD and MDD, including Dr. Delaney and Dr. Peters. Dr. Webb also found in April 2003 that the Veteran had mixed personality disorder, with paranoid, antisocial and narcissistic features, but no evidence of cognitive impairment. More recently, this examiner saw the Veteran in February 2006 for a disability evaluation while the Veteran was incarcerated in a low security prison due to perjury. This particular offense seemed to fit the Veteran very well along with his tendency to file law suits against individuals whom he viewed as having wronged him. He was noted to have told his primary care doctor he had more flashbacks and more verbal aggression over the past year for reasons unknown to him. Socially he was very irritable and tended to keep others at a distance and had paranoid thoughts about fears of attack by strangers. His mental status examination was similar to that 3 years earlier, with poor eye contact and mild agitation. He was showing new symptoms of auditory hallucinations and said they were rare. This doctor's diagnosis was unchanged from 3 years earlier with respect to chronic PTSD, and recurrent major depression with panic. The Veteran reported being sober from alcohol for over a year. His paranoid ideations were more intense. The Axis II personality disorder was unchanged, mixed personality disorder involving antisocial and paranoia. Social Security records include copies of various batteries of psychiatric tests administered to the Veteran throughout the pendency of this appeal. They also include records of psychiatric treatment and evaluation by private medical providers. These include handwritten notes suggesting treatment for psychiatric complaints in August 2001, with problems noted to include conflicts at work and having gone through a bad divorce and bankruptcy, and panic attacks triggered by these problems. Testing done in September 2001 were noted to suggest possible Axis I diagnoses of adjustment disorder, unspecified, rule out PTSD and Axis II deferred, rule out mixed personality disorder with borderline, narcissistic, paranoid features. Trauma inventory also dated in September 2001 also was interpreted as suggesting he was suffering PTSD reactions and symptoms, including flashbacks, nightmares, upsetting memories and repetitive thoughts of unpleasant past experiences; however, his score on the inconsistent response scale indicated that he did not respond in a consistent manner, which may suggest a reduced attention span. Among the Social Security records is a March 2006 report from the Chartiers Mental Health/Mental Retardation Center which related the history of a diagnosis of PTSD by VA in 1995. The Veteran denied treating for PTSD until 2002 and his chief complaint of not getting enough good treatment at the VA. His history in Desert Storm included service in Saudi Arabia for 1 week and service in Egypt. He claimed to have witnessed "a lot of stuff I don't want to share." He claimed while over there he was in the "secret service" and upon his return he started having problems with anger and could not relax, being constantly on edge. He reported nightmares. He claimed that he did nothing about this until 1995 when he went to a VA hospital and was diagnosed with PTSD. He claimed that he then requested compensation from VA and was denied. He also related a history of being harassed at work and claimed that he was being watched and followed and was fired from his job in 2001, and after getting his job back in 2002, was fired again upon his return. He gave a history of being diagnosed with schizophrenia by Dr. Webb, his treating psychiatrist for the past 2 years. He reported paranoia, feeling people were following him and monitoring his phone calls. He described hearing voices on and off since 1996. He also reported a history of hypervigilance and fearfulness. Current symptoms were described as flashbacks, but when he described them, he was very evasive. He also reported nightmares both of his Gulf experiences and of his negative experiences with the police. He denied suicidal or homicidal ideations, depression, anxiety, or panic attacks. Mental status examination was remarkable for his having very poor eye contact and being very evasive and secretive. His mood was anxious and thoughts were very paranoid and delusional, with impaired reality testing. In summary he was described as claiming his diagnosis was PTSD, but according to his psychiatrist, Dr. Webb, his diagnosis was schizophrenia and he was paranoid and delusional. The last time he heard voices was a couple months ago. The Axis I diagnosis was history of PTSD, psychotic disorder NOS-rule out schizophrenia and alcohol dependence in remission. The examining doctor offered outpatient treatment but he refused. It was recommended that he be further observed and have more intense treatment, in order for a clearer diagnosis to be made, but he claimed he just wanted medication, which when offered he was reluctant to take. An August 2006 record from Mercy Behavioral Health noted the Veteran to present seeking treatment for PTSD from the Gulf War, with a history of having been in the Army for 6 years and with the police department for 12 years. He gave a history of being fired by the police due to an inability to get along with others. He reported still having nightmares twice a week about the war, racing thoughts and trust issues, He disliked being around people but had a few friends. He reported seeing shadows out the corner of his eye at times. An October 2006 psychiatric evaluation by Mercy Behavioral Health noted complaints of anxiety, nightmares, panic and severe reaction to stress, with unremarkable mental status findings and a diagnosis of PTSD rendered, but no opinion as to etiology given. Also among the Social Security Records was a February 2007 clinical disability evaluation. The detailed background of the Veteran was cited including a reportedly good childhood and uneventful pre-Persian Gulf history. His post-service history of being fired in 2002 after 12 years as a police officer was reported by him as taking place because "the chief didn't like me and had me railroaded for a crime I did not commit." He was not presently working and blamed PTSD that he said originated in service and worsened while he was a police officer. The history of a 10-month incarceration for perjury was noted. He indicated that this happened because he had sued the chief for harassment but did not elaborate on the nature of the alleged harassment other than multiple attempts to fire him. On clinical evaluation he appeared calm and not at all anxious, despite his reports of anxiety. He claimed he first experienced mental health symptoms during the war when he started having flashbacks of what he had done at that time. He described the "flashbacks" more as nightmares, anxiety, paranoia and very high stress levels. He claimed he first sought help with the VA in 1994 when he saw a series of doctors but had no prescribed medications. He said the VA accused him of just trying to get a pension. He claimed that he next sought help from the VA in 2004 and was sent for tests related to the pension, but was very vague about this situation. He stated that at that time he was prescribed medications. He reported last seeking treatment at the VA in 2006 but was not satisfied with their services, so went to Mercy Behavioral Health. Regarding current symptoms he reported flashbacks most recently after a helicopter flew over his house. He described these flashbacks as "panic attacks" with physical manifestation such as rapid heartbeat and wanting to run away somewhere. He reported these a couple times a week. He denied being hospitalized but had a history of being placed on various medications for his symptoms. He endorsed homicidal ideations towards the people on the police force who "railroaded" him. He also related a drinking history from age 15 until 1998. He reported feelings of hopelessness and helplessness. He denied symptoms of worthlessness, guilt, or regret. He denied symptoms of a thought disorder and none was apparent during an interview. He described his mood as varying from sedate to hostile and endorsed road rage. He described high levels of depression and anger and moderate levels of anxiety. He reported sleep problems, primarily from nightmares and panic attacks. He got good sleep some nights and other nights would wake up screaming. He was oriented in all spheres, had some slightly impaired immediate memory, and also had impaired concentration and judgment. The examiner in the February 2007 evaluation described the Veteran's veracity as questionable at times. He was noted to show some indicators of this by exhibiting low motivation on formal test measures of cognitive impairment as well as on judgment and social judgment. He was vague at times and was noted on cognitive testing to be unable to provide an adequate response to a question that was deemed at odds with his level of military experience. Lastly, the Veteran appeared to persistently return to talking about his diagnosis of PTSD whenever he could, yet exhibited no external displays of such a diagnosis during the interview. Therefore, the question was raised as to whether he was exaggerating some symptoms as a cry for help or for some other reason. The Axis I diagnosis was adjustment disorder, mixed anxiety, depressed mood, and alcohol dependence in sustained full remission. The examiner stated that the Veteran was distressed but the etiology of the stress was somewhat questionable. The Veteran mentioned symptoms that were inconsistent with his presentation such as his claims of repeated panic attacks that were severe and multiple in nature. However, he was very calm and in fact did not move or fluctuate in his voice or posture during the entire evaluation. He seemed comfortable and answered questions without having to have them repeated. He mentioned vague symptoms of PTSD. However he did not meet the criteria for PTSD based on his interview. It appeared that he was very angry towards the police force and those who convicted him "wrongfully" for charges that resulted in jail time. He appeared to have difficulty adjusting to being convicted of a crime and of letting go of his anger towards those he felt wronged him. It was felt that it was likely the Veteran may have felt different emotions as a result of different situations over the past 20 years; however, it was likely that each situation warranted individual attention and was not a precursor to subsequent events or feelings. In this way he was described as appearing to be in recovery from alcoholism and having difficulty adjusting. His prognosis was poor as he appeared to be persistent in attempting to receive treatment for PTSD symptoms and has gone so far as to have sought alternate doctors who would diagnosis PTSD. He was noted to have apparently low motivation and at times his veracity was questionable. Records from Mercy Behavioral Health include a July 2006 initial intake date and discharge date of May 3, 2011, with a primary diagnosis of PTSD. A provisional diagnosis made in August 2007 was of depressive disorder, anxiety disorder NOS and antisocial personality. Active prescription lists from January 2007 to December 2011 showed that the Veteran's active prescriptions from January 2007 included psychotropic medications, including Abilify, Celexa, and Klonopin. Records including a last service date of August 2010 indicated the Veteran initially presented with PTSD from the Gulf War, with a history of being in and out of treatment for 10 years with VA. He reported problems trusting people and indicated that despite attending sessions he found it did not lower his level of suspicion towards others and found it difficult to socialize outside of his family. A diagnosis of PTSD was given. A record indicating a last service date of December 2010 described him as having initially presented with some PTSD symptoms in the Gulf War, but indicated road rage was a bigger concern. He was given Axis I diagnoses of panic disorder, rule out agoraphobia, depressive disorder NOS, PTSD and antisocial personality. The report of an August 2011 VA examination revealed the claims file was available and reviewed, with the most recent VA examination of 2004 noted to have shown a diagnosis of adjustment disorder with depressed mood secondary to multiple life stressors unrelated to military service and alcohol dependence in short-term remission. His GAF back then was 70, indicating some mild symptoms. Prior to that examination he had been seen for evaluation at Highland drive VA behavioral health and had been diagnosed with "Malingering PTSD" and adjustment disorder with anxiety secondary to job loss and legal difficulties. His GAF was again 70. Most recently he was evaluated in August 2011 and diagnosed again with adjustment disorder with anxiety and depressed mood. Current findings revealed he was generally cooperative and pleasant. He underwent psychological testing. He reported his childhood as unremarkable for any unusual illnesses, injuries or abuse. He denied any pre-military legal problems or socialization issues. His military stressors included being an unarmed plain clothes policeman in Egypt with an incident of having 2 vehicles park behind and in front of him, and thought the occupants were going to pull a weapon on him. The examiner noted that the Veteran's report showed no indication of any threat and noted no attempt by the other drivers to detain the Veteran in any fashion. This incident was noted to have been unverified and there was no evidence presented by the Veteran that this presented a threat of any hostile military or terror activity. The examiner stated that it was unclear how this was a traumatic stressor, given that nothing happened. It was also noted that no hostile activity took place on or around the base. The Veteran reported no other specific type of stressor other than just a feeling of doom and gloom. He cited being told that a terrorist could strike at any time and they were always hypervigilant. He also indicated nothing really happened when he was in Saudi Arabia, except being told that the Iraqis had SCUDS with poison that could reach them. The Veteran spent one week there in December 1990 long before any SCUDS were fired. He was under no threat of missiles in Egypt. He also provided no evidence of any kind of traumatic or stressful event occurring in service and provided no evidence or description of hostile military or terrorist activity. The Veteran's post military history was noted to be significant for working as a police officer from 1990 to 2002 when he was fired for an incident in which he was eventually convicted for perjury surrounding calls made to the Police Chief's house that alleged domestic violence. He denied any other legal history. His current illness history was that he reported psychiatric symptoms first in the mid 1990's with stress surrounding a criminal case that involved his father and the IRS. However he indicated that after service, he never wanted to be without a gun again. He had nightmares about the special plain clothes mission and a lot of anger at the military for putting him in that position. The examiner reviewed records regarding his history of psychiatric treatment, noting that the first treatment he reported at VA in 1995 actually was for VA examination purposes and the Veteran confirmed this, with no follow up or treatment. He did not seek treatment until 2004 by Dr. Marcario for PTSD evaluation and was found to be apparently fabricating symptoms of PTSD and diagnosed with adjustment disorder. Subsequent treatment was noted to include treatment until 2006 when he stopped seeing Dr. Young because she would not fill out a form indicating he was unemployable. He transferred to Mercy Behavioral Health and treated there until March or April 2011 but left because he was unhappy with the care he was getting. He was noted to have been diagnosed with adjustment disorder in August 2011. His substance abuse history was noted to be significant for treatment at a private facility for alcohol problems. His complaints were of a lot of anger, getting easily angered and avoiding people. He shopped at Wal-Mart at night to avoid people. He reported nightmares a couple times a month with some content about service and other content about work issues. He sometimes drank twice a week. Mental status examination revealed adequate dress, grooming and hygiene. He had good orientation, he was alert and responsive and understood the purpose of the examination. He was somewhat detached in his manner, with fair eye contact and normal speech. His mood was pleasant and neutral with somewhat restricted affect. There was no evidence of hypervigilance, hyperalertness or hyperarousal of any kind. The Veteran reported his mood was bad and angry and it was difficult to put things in perspective; however, throughout the interview he appeared cheerful and pleasant. His appetite was normal and he complained of weight gain. He got 8-9 hours sleep each night and took less than 30 minutes to fall asleep. He had no significant continuity disturbance but had dreams twice a month that appeared to be about violent behaviors by the Veteran and only occasionally about the special mission. He had no homicidal or suicidal ideations. He had no hallucinations or delusions. His thought processes appeared logical and sequential. He had no dissociative symptoms and no ritualistic or obsessive behaviors. He had no somatic complaints. He reported drinking 2-3 times a month. He socialized with 2 friends from the police department whom he saw for coffee or lunch, but otherwise did not socialize much. He had no relationships since his divorce and avoided one since he did not want to be involved with anyone. His insight and judgment did not appear impaired. The Veteran was administered a battery of psychological tests, with findings that overall testing did not support a diagnosis of PTSD but rather some problems with hostility consistent with his report as well as some mild adjustment-related difficulties. The Axis I diagnosis was adjustment disorder with depressed mood unrelated to military service and alcohol dependence in partial sustained remission. His GAF was 70. The examiner summarized that the results of testing clearly indicate there is no evidence of any kind of a traumatic stressor experienced by the Veteran during his service. He was not exposed to direct combat and at no time was exposed to terrorist or hostile activity. At no time did he experience, witness or was confronted with an event or circumstance involving actual or threatened death or serious injury to himself or others. It was noted that he was not exposed to fire during the one week in Saudi Arabia and he was not threatened or detained and saw no weapon. Overall there was no evidence to suggest exposure to an actual stressor and no symptoms or problems based on fear of hostile military or terror activity. The examiner pointed out that virtually all the evaluations in his claims file were consistent with the diagnosis of adjustment disorder and some with personality disorders. There was some suggestion of malingering and symptom exaggeration concerning his reports. While there did appear to be a VA examination from the VA Dr. Rosenburg in 1994 (actually 1995), indicating a diagnosis of PTSD, this examiner viewed this as entirely unacceptable, having no description of a traumatic stressor of any kind and simply based on the Veteran's reports of symptoms that have no particular relationship to any particular experiences encountered in the military. Most recently his evaluations in 2004 by Drs. Macario and Eberle clearly indicated an absence of any traumatic stressor or PTSD symptoms consistent with more recent evaluations resulting in a diagnosed adjustment disorder with depressed mood by several clinicians. Overall his current symptoms resulted in a diagnosis by several clinicians of adjustment disorder in no way related to service. There was also no evidence of exposure to a stressor. Additionally he reported no PTSD symptoms in full spectrum. He had no evidence of hyperarousal, hypervigilance, or other such symptoms. He reported nightmares twice a month, many of which were entirely unrelated to service but more so to his experiences at the police department. Finally, psychological testing did not show evidence to suggest symptoms consistent with PTSD. The report of an April 2013 VA examination gave an Axis I diagnosis that concluded the Veteran does not have a mental disorder that conforms with DSM-IV criteria. Thus no Axis I mental disorder was diagnosed. He had no diagnosis of TBI. The claims file was reviewed. His history was noted to reveal he denied any social or family problems in childhood. He also denied any social problems in the military although he described some interactions with superior officers as abusive. He was divorced since 2000 with no romantic relationships since, and had limited contact with his teenage daughter as he did not get along with her mother. He described family members such as parents, siblings and extended family as social supports. He lived with his parents. He enjoyed reading military history and denied other hobbies. He denied academic or occupational problems prior to service and was noted to have enlisted in the Army Reserves in 1985 and was transferred to the Air National Guard where he served from 1989 to 1991 including his active service from December 20, 1990 to June 5, 1991. The history of being deployed to Saudi Arabia for a week and then in Egypt the rest of the time was noted. His duties were of guard duty in the airfield and tent city. His combat exposure revealed he denied discharging a weapon, incoming fire or exposure to explosives or human remains. He reported a SCUD went off in Saudi Arabia while his old unit was there, but he was already in Egypt. He reported having served with the police after service from 1990 to 2002 and was fired because his dispute with the Chief of Police resulted in his arrest for perjury and he indicated that legal matters were still pending regarding this. The records reviewed by the examiner also showed that he was referred for private alcohol treatment by his union in 1998 following his unauthorized use of police department letterhead for personal use. The examiner reviewed the records that showed he was fired for lying about domestic violence calls to the Police Chief's house and was convicted and sentenced to 10 months in Federal prison for perjury. He was noted to not report this incident during the evaluation. He was noted to currently attend community college, studying to be a paralegal and was getting good grades. He denied academic problems or problems with concentration. He denied mental health treatment during childhood or in the service. His mental health history reviewed in the records included the alcohol rehabilitation in 1998 and was said to have first sought PTSD treatment in 2004 with the PTSD clinic psychologist not finding him to have PTSD, but rather that he was fabricating PTSD symptoms. He was noted to have been seen for psychiatric and psychological treatment until 2006 and was not diagnosed with PTSD. He was noted to have transferred his case to private treatment at Mercy Behavioral health until March or April 2011 and then resumed treatment with a VA psychiatrist in August 2011 and was diagnosed again with adjustment disorder. He was noted to also have been treated at the Vet Center but discontinued due to issues with the individual medical provider. He currently was prescribed Abilify, Clonazepam and Celexa by a non-VA psychiatrist. There was no evidence that this treating doctor conducted a full PTSD assessment and it was unclear how this medication benefited the Veteran. The examiner noted that the 1995 VA examination, which diagnosed PTSD, had no description of a traumatic stressor of any kind, and was based on a report of symptoms without demonstrating a relationship to any particular experiences encountered by the Veteran in the military. He was noted to have since been assessed for PTSD by 2 additional VA examinations in 2004 and 2011 and each time had not been diagnosed with PTSD; nor were symptoms consistent with PTSD. In support of this opinion, the examiner stressed that the Veteran denied a pre-military and military history of psychological or psychiatric problems. His post-military history was significant for the perjury charges, and he was noted to be vague about these legal charges as well as his prior history of misconduct behaviors in the police department. He denied current substance abuse or dependence but cited drinking 0-2 standard drinks per week. He reported that at his heaviest drinking he drank a 6-pack every couple of weeks after the Gulf War. Again the history of completing alcohol rehabilitation in 1998 was noted. Other sentinel events besides his stressors including responding to motor vehicle accidents as police officer but denied any PTSD or mental health symptoms related to these events. He underwent a series of tests including tests for depression and for PTSD. The overall testing was consistent with minimal psychiatric symptoms. Regarding subjective complaints, the Veteran complained of trouble sleeping but denied all forms of insomnia and got 8 hours of sleep per night. His primary complaints regarding sleep were of sometimes being restless and sometimes having bad dreams, which were unrelated to his service trauma but rather about fighting someone. He reported a history of anger problems and road rage but also indicated his mood had significantly improved because he had school to preoccupy him. Regarding his reported stressors of being "boxed in" by 2 vehicles in Egypt, he indicated that although he thought something bad could happen (terror attack) nothing did. Regarding the SCUD missile firing near his unit in Saudi Arabia, he was noted to be in Egypt at the time. He denied any direct exposure to any missiles fired overseas. Overall he did not report any forms of hostile military or terrorist activities overseas. The examiner found that none of the stressors reported to be related to the Veteran's fear of hostile military or terrorist activity. The examiner concluded there was no exposure to a traumatic event. The Veteran was found to not meet the full criteria for PTSD. Additionally, the Veteran did not have any other symptoms attributable to PTSD and any other mental disorders not listed above. The examiner summarized that the Veteran's symptoms did not meet any criteria for any Axis I disorder. He clearly did not meet the criteria for PTSD; nor has he ever met the criteria for PTSD in the past. The Veteran's reported PTSD stressors have been consistent across evaluations and consistently have not met the Criterion A for a diagnosis of PTSD. The examiner noted that the SCUD attack had been conceded by the Appeals Management Center (AMC) but the Veteran reported he was in a different country at the time and reported to his knowledge that nobody was harmed. By his report during the evaluation and his responses on psychiatric testing, he did not experience, nor witness, nor was confronted with an actual event that caused significant distress. He related all his combat related military events as only a little bit distressing at the time of the event. His reported stressors were thoughts about situations that could happen but did not. Also the examiner noted that even if the Veteran reported a criterion A stressor, this alone was not sufficient for a diagnosis of PTSD. During this evaluation the Veteran did not report a single PTSD symptom to this examiner. When specifically asked about possible PTSD symptoms the Veteran specifically denied the following hallmark symptoms of PTSD: reexperiencing symptoms, avoidance related to traumatic event, feelings of detachment, problems with concentration and hypervigilance. The only reported symptom was "sleep problems" but when queried, he reported 8 hours of sleep per night without insomnia. His records document a history of distress primarily in response to psychosocial stressors (such as divorce, problems with employment) likely exacerbated because of personality factors. Today he was reporting improvements in mood and overall minimal psychological distress. This appeared related to his current college training, which gave him some hope about his future employment and something productive to do during the day. He had a documented history of substance abuse and denied such symptoms currently. The past substance abuse was unrelated to service. Although he had a history of interpersonal problems while working for the police department, these were unrelated to service. He reported significant improvement in symptoms compared to his past evaluations. In regards to his current psychiatric symptoms, he remained fully employable at this time and would be able to tolerate the normal stress, interpersonal activities and schedule requirements inherent to any work environment. Based on a review of the foregoing, the Board finds the preponderance of the evidence is against the claim of service connection for an acquired psychiatric disorder, to include PTSD. The Board lends greatest weight to the most recent VA examination of April 2013, which includes obtaining a detailed history, examination (including testing), claims file review and comprehensive explanations of the rationale for determining that the Veteran has not met the criteria for a diagnosis of PTSD. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The examiner pointed out that the Veteran's responses on testing were not consistent with PTSD, even if a criterion A stressor were determined to be met, (as conceded by the AMC in March 2013). This examination also determined that the Veteran met no criteria for any Axis I psychiatric disorder , again providing a detailed rationale noting that he was currently doing well, with no sleep problems other than bad dreams, some of which were unrelated to service. His records were described as showing distress, primarily in response to situational stressors that included major employment and legal issues and divorce, exacerbated by personality factors. With the improvement of his current situation, he was found to have no evidence of psychiatric or cognitive issues. While this examination is found to conclude that no current psychiatric disability exists, the Board notes that the Court has held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The unfavorable nexus opinion from the April 2013 VA examination are further supported by other medical evidence, to include medical evidence showing the Veteran to have various psychiatric disorders diagnosed during the course of this appeal, which the evidence reflects were not related to service or any incident therein. This includes the findings from the February 2004 and August 2011 VA examinations that diagnosed adjustment disorder with depressed mood, both times found to be related to his life stressors unrelated to service. These examinations also provided adequate rationale for their findings, including conclusions drawn from the results of tests administered that the Veteran did not truly meet the criteria for PTSD, and findings that the Veteran appeared to be exaggerating symptoms and possibly malingering. Additional medical evidence that questioned the validity of his claimed symptoms is shown in the February 2007 clinical psychological disability evaluation in the Social Security records, which questioned the Veteran's veracity and noted that his responses on testing and his claimed symptoms were inconsistent with his claimed PTSD. This evaluator also suggested that the Veteran appeared to be seeking doctors who would diagnose PTSD. Again the opinions questioning his veracity were made following testing and interview with the Veteran. The diagnoses rendered in February 2007 of adjustment disorder, mixed, anxiety and depressed mood and alcohol dependence in full sustained remission have not been linked to service. The findings of an April 1999 psychology evaluation that included testing and interview for the purpose of establishing treatment, also raised questions of his motivation for seeking the evaluation, noting the Veteran's symptoms were not consistent with a PTSD diagnosis and indicated that the Veteran appeared more interested in financial gain rather than treatment, suggesting that secondary gains were a possible motivation for his attempts to document combat-related difficulties. While multiple Axis I diagnoses were rendered in April 1999 of adjustment disorder with mixed anxiety and depressed mood, alcohol dependence in sustained full remission, major depressive disorder, dysthymic disorder and factitious disorder with combined psychological and physical signs and symptoms, none of these diagnosed disorders was found to be related to service. That a factitious disorder was found also is highly suggestive of the Veteran feigning disability for secondary gain. In contrast, the Board finds that the August 1995 VA examination's assessment of PTSD was not supported by a rationale, and was rendered based only on examination without testing and, thus, is of unconvincing probative value. Sklar v. Brown, 5 Vet. App. 140 (1993). Additionally, the Board considers it significant that the private medical providers who diagnosed PTSD, including Dr. Delaney and Dr. Webb, and the medical providers who assessed PTSD during his incarceration appeared not to have had access to the Veteran's claims folder and did not complete full testing. See 38 C.F.R. § 4.1 (2012). The Board acknowledges that claims folder review is not a requirement for medical opinions, and that a medical opinion may not be discounted solely because the opining clinician did not conduct such a review. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, their findings of PTSD appeared to be based on interviews without diagnostic testing. These assessments of PTSD appears to be based entirely on the Veteran's unsubstantiated statements at the time of the examinations and treatments. A medical opinion premised upon an unsubstantiated account of a claimant may be found to be of lesser probative value. Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993). The Board is mindful that the Veteran has asserted that he has experienced chronic psychiatric problems as a result of his in-service stressors, upon which the diagnoses of PTSD made in the August 1995 VA examination and the other favorable opinions from other medical providers. Lay evidence is one type of evidence that the Board must consider when a veteran seeks disability benefits. 38 C.F.R. § 3.307(b) (2012). In weighing credibility, VA may consider inconsistent statements, internal inconsistency and consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, the Board has reason to question the credibility of the Veteran's contentions as the more probative medical evidence has repeatedly demonstrated issues with his veracity and evidence of symptom exaggeration with malingering. Additionally the Veteran's credibility is undermined by evidence of his having been convicted of perjury, an offense that specifically goes to the Veteran's credibility. Accordingly, the Board considers the assessments of PTSD made by the VA and private medical providers, which are based on the Veteran's reported symptoms, to be of no probative value, especially because they were based on an inaccurate premise set forth by the Veteran. Negative opinions provided by the February 2004, August 2011 VA and April 2013 VA examiners and the February 2007 clinical psychological disability evaluation for Social Security included comprehensive testing and discussion of the rationale for the unfavorable findings. These negative opinions convincingly show that the Veteran never has had PTSD established by his meeting all the criteria required by DSM-IV, which criteria were supported by complete psychological testing. Although the examiner in a September 1998 VA examination did suggest some anxiety related to his Persian Gulf service, this examiner suggested these symptoms would improve with sustained abstinence from alcohol and improvement in his interpersonal conflicts at work. This implies that the anxiety was in fact due to other problems, such as the Veteran's alcohol abuse. The examiner also noted that the Veteran did not meet the criteria for PTSD, and described a number of work related stressors contributing to his psychiatric diagnoses. The Axis I diagnosis was noted to be of alcohol dependence in early remission and depression NOS. Many of his symptoms were said to have already resolved with treatment of his alcoholism. Thus, this examination report does not support a basis for granting service connection for any psychiatric disorder. In sum, the Board finds that the preponderance of the credible evidence weighs against a finding that any currently diagnosed psychiatric disorder developed as a result of an in-service stressor or is otherwise related to the Veteran's active service. Nor does the record show that any psychosis manifested to a compensable degree within one year following the Veteran's separation from service. 38 C.F.R. §§ 3.307, 3.309. Therefore, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for an acquired psychiatric disorder and that claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2011); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for an acquired psychiatric disability, to include PTSD, is denied. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs