Citation Nr: 1326499 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 10-31 707 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for sinus disorder. 2. Entitlement to service connection for a respiratory disability, to include as secondary to sinus disorder. 3. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive disorder. 4. Entitlement to service connection for headaches, to include as secondary to sinus disorder or an acquired psychiatric disability. 5. Entitlement to service connection for a colon condition or gastro esophageal reflux disease (GERD), to include as secondary to an acquired psychiatric disability. 6. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disability. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1977 to February 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Hartford Regional Office (RO) in Newington, Connecticut. In November 2010, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. The Veteran was provided an opportunity to set forth his contentions at the hearing. The record reflects that at this hearing the undersigned set forth the issues to be discussed at the hearing, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. These actions satisfied the duties a Veterans Law Judge has to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). A copy of the hearing transcript has been associated with the claims folder. In July 2011, the Board remanded the matters on appeal to the RO (via the Appeals Management Center (AMC)) for additional development. The Board instructed the RO to send the Veteran additional notification regarding his claim for PTSD due to personal assault, obtain copies of his service personnel records, and provide him with VA examinations to determine the nature and etiology of his claimed conditions. A review of the claims folder reveals that there has been compliance with the Board's remand directives, no further action is required and the Board may proceed with adjudication of the claim. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In February 2013, the Board solicited an expert medical opinion from a physician with the Veterans Health Administration (VHA) concerning the nature and etiology of the Veteran's psychiatric disorder, to include personality disorder. In April 2013, the Board received the requested VHA opinion. A copy of this opinion has been sent to the Veteran and he has not responded with any additional arguments. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The Veteran had surgical intervention for thyroglossal duct cyst four times prior to his enlistment into service. 2. The medical evidence clearly shows that the Veteran's pre-existing thyroglossal duct cyst with excision and revisions was not permanently aggravated during his period of service, to include his complaints of recurrent sinus tract infections; and a current diagnosis of chronic sinusitis is not shown. 3. The preponderance of the competent medical and lay evidence is against a finding that the Veteran has a current respiratory disorder that was incurred or aggravated during his period of service or that is otherwise related to active duty, to include inservice exposure to heavy dust and paint chips. 4. The Veteran's personality disorder, diagnosed in service, is a congenital or development defect not subject to compensation within the meaning of applicable legislation, and there is no evidence that shows a superimposed disease or injury during service created any additional psychiatric disability. 5. There is no medical evidence that establishes that the Veteran has a current diagnosis of PTSD in accordance with § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 6. An acquired psychiatric disorder, including anxiety disorder, was not shown during service, or for years thereafter, and the weight of the medical evidence is against a link between any current or previous diagnosed psychiatric disorder and service. 7. The Veteran's headache disorder did not have an onset during service, and the preponderance of the competent evidence is against a finding that it is related to active duty, to include inservice exposure to heavy dust and paint chips. 8. The Veteran's hypertension did not have an onset until decades after his separation from service, and the preponderance of the competent evidence is against a finding that it is otherwise related to active duty. 9. The Veteran's GERD and recurrent diverticulitis did not have an onset during service, and the preponderance of the competent evidence is against a finding that either disorder is related to active duty. CONCLUSIONS OF LAW 1. The criteria for service connection for sinus disorder have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2012). 2. The criteria for service connection for a respiratory disorder have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 3. The criteria for entitlement to service connection for a psychiatric disorder, to include a personality disorder, have not been met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 4.125 (2012); VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990). 4. The criteria for service connection for headache disorder have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 5 The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 6. The criteria for service connection for a colon condition and/or gastro esophageal reflux disease (GERD) have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations requires VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the 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. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided to a claimant prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In this case, the Veteran was advised in September 2008 and July 2011 of the evidence and information necessary to substantiate his claims, and the responsibilities of the Veteran and VA in obtaining such evidence. In the July 2011 letter, he was specifically notified on how to substantiate a claim for service connection for PTSD based on personal assault. In both letters, the Veteran was further advised of the evidence and information necessary to establish a disability rating and an effective date, in accordance with Dingess/Hartman. The VCAA requires that the duty to notify is satisfied, and that claimants are given the opportunity to submit information and evidence in support of their claims. Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with the issuance of a decision on the merits as to his claim for service connection. Any timing defect was cured by the subsequent readjudication of the Veteran's claim, to include in a September 2012 Supplemental Statement of the Case. See Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006); Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). In addition to its duty to notify, or inform, the Veteran with regard to his claim, 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 treatment records and records of pertinent medical treatment since service, and providing the Veteran a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the available record includes service treatment records from his second period of service, service personnel records, post-service VA and private medical treatment reports, and the Veteran's own statements. To the extent that any more recent records may remain outstanding, there is no indication that they are necessary for a fair adjudication of the Veteran's claims. The Board finds that the notice requirements pertinent to the issues on appeal have been met and all identified and authorized records relevant to the matters have been requested or obtained. There is no evidence that any additional relevant treatment records exist, and the Veteran has not so alleged. The record indicates that the Veteran applied for Social Security Disability benefits with the Social Security Administration (SSA). SSA records normally are relevant to a claim and VA must obtain them where either (1) there is an SSA decision pertaining to a medical condition related to the one at issue or (2) there are specific allegations "giv[ing] rise to a reasonable belief" that the SSA records may pertain to the claimed disability. Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). In this instance, the Veteran never made any statements indicating that his SSA claims file contained records not currently found in the claims file pertaining to his claims. Moreover, the report of a February 2012 VA psychiatric examination shows that the Veteran informed the examiner that he receives SSA disability benefits because of his deep venous thrombosis and his lumbar spine disorder, and not for any of the current matters pending on appeal. As the Veteran has not made any specific allegations giving rise to a reasonable belief that the SSA records may contain information pertaining to his current claims on appeal, and the SSA decisions were based solely on economic eligibility matters, the Board finds that the Veteran's SSA records are not pertinent in this matter; therefore, a remand to procure the SSA records would serve no useful purpose, and would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board acknowledges that the Veteran has alleged in-service exposure to asbestos. In McGinty v. Brown, the United States Court of Appeals for Veterans Claims (Court) observed that there has been no specific statutory guidance with regard to claims for service connection for asbestos-related diseases, nor had the Secretary promulgated any regulations. McGinty v. Brown, 4 Vet. App. 428, 432 (1993). However, VA has issued a circular on asbestos-related diseases, entitled Department of Veterans Benefits, Veteran's Administration, DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) (hereinafter 'DVB Circular'), that provides some guidelines for considering compensation claims based on exposure to asbestos. Id. The DVB circular was subsumed verbatim as § 7.21 of Adjudication Procedure Manual, M21-1, Part VI. (This has now been reclassified in a revision to the Manual at M21-1MR, Part IV, Subpart ii, Chapter 2, Section C.) See also VAOPGCPREC 4-00 (Apr. 13, 2000). A September 2008 response from the National Personnel Records Center (NPRC) reflects that VA has performed the necessary development and has determined that the Veteran's military occupation of Seaman resulted in minimal exposure to asbestos in the Navy. No further development regarding asbestos exposure is required. Pursuant to the Board's July 2011 remand directives, the Veteran was provided with VA examinations in February 2012 in conjunction with his claims. In each examination report, the examiner identified the nature of the Veteran's claimed disorder and recorded his reported history as well as the findings from clinical examination. The VA examiner provided a comprehensive statement in support of her medical conclusions on etiology of each identified disorder, which in concluded both direct and secondary service connection considerations. The Veteran was also provided with a February 2012 VA psychiatric examination, in which the examiner recorded the Veteran's reported history and clinical findings from examination. The VA psychiatric examiner provided medical conclusions regarding the etiology of the Veteran's diagnosed personality disorder; however, the Board found the examiner's terminology to be problematic. The Board then obtained a VHA medical opinion in April 2013. This report demonstrates that the medical examiner reviewed the evidence of record and rendered an appropriate opinion based on the question presented by the Board. This opinion was rendered after a thorough review of the claims file and is supported by the evidence of record. Any deficiencies in the February 2012 VA psychiatric examiner's opinion were resolved by the April 2013 VA medical expert's report. The Board finds that the medical opinions are adequate for adjudication purposes, and the adequacy of this medical opinion is discussed in further details below. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO/AMC has substantially complied with the Board's February 2011 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with respect to the issues on appeal have been met. 38 C.F.R. § 3.159(c)(4). In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of these issues has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claim. See 38 C.F.R. § 3.103. He has retained the services of a representative, and he testified before the undersigned Board member. 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran has claimed entitlement to service connection for a sinus disorder; a respiratory disorder; headaches; an acquired psychiatric disorder, to include PTSD, generalized anxiety disorder, and major depressive disorder; a colon disorder or GERD; and hypertension. These claims, most specifically the sinus disorder and respiratory condition claims, include a claim based on direct theory of service connection due to the Veteran's in-service duties sanding and chipping paint as a boatswain's mate. He also claims that he was exposed to asbestos in service. The Veteran has claimed that his sinus disorder, which existed prior to service, was aggravated through these in-service duties. He has also claimed that the respiratory condition and the headaches may have been incurred or aggravated secondary to his sinus disorder. The Veteran has contended that he developed an acquired psychiatric disability, to include PTSD, generalized anxiety disorder, and major depressive disorder, due to the trauma associated with having to perform duties that he believed were making him sick or due to conflicts he had with other crewmembers. He has claimed that his colon condition, headaches, and hypertension developed secondary to an acquired psychiatric disability. The Board finds that the Veteran's service treatment records corroborate his reported exposure to heavy dust and paint chips in service. Specifically, the Board notes a December 1977 mental health treatment record reflects that the Veteran "feels his petty officers are trying to get him to act out by playing games with him (hiding [sic] of sanding equipment etc)...." A January 1978 service treatment record reflects that the Veteran's sinus tract "gets infected with exposure to dust." In addition, the Veteran testified during the November 2010 Board hearing that his duties consisted of "sanding and chipping paint" with "no respiratory - no mask, no gear, nothing to help [him] breathe" while he chipped off "lead paint." The Board finds that the Veteran's lay statements regarding inservice exposure to heavy dust and paint chips, which is further corroborated by notations in his service treatment records, to be both competent and credible, as well as consistent with the Veteran's service. 38 U.S.C.A. § 1154(a). Sinus and Respiratory Disorders The Veteran seeks entitlement to service connection for sinus and respiratory disorders. He contends that his pre-existing sinus condition was aggravated by his period of service, to include his in-service exposure to heavy dust and paint chips. He further contends that he has current respiratory problems are also related to his inservice exposure, or as secondary to his sinus condition. On his June 1977 enlistment medical history report, the Veteran reported that he had a history of excision of a thyroglossal cyst in September 1973. His associated medical enlistment examination revealed normal mouth and sinuses, but it was noted that the Veteran had a scar on his neck as a residual from the excision of thyroglossal duct cyst. A July 1977 treatment note shows that the Veteran presented with complaints of drainage from the scar on his throat and pain to the right side of the scar. It was noted that he had possible recurrent thyroglossal cyst draining and he was referred for surgical consultation. A July 1977 general surgery clinic consultation report shows that the Veteran had a history of thyroglossal duct cyst, status post four surgical interventions, with the most recent in 1974. He reports that since his last surgery, he has had occasional symptoms, including swelling of around base of his tongue and drainage. In August 1977, an x-ray exam with dye injection revealed a sinus tract which drained near base of the Veteran's tongue. It was noted that the Veteran denied any problems with drainage at that time, and the physician noted that surgery was not recommended unless the Veteran complained of current problems. A November 1977 ENT clinic consultation report shows that the Veteran had a diagnosis of thyroglosssal duct fistula based on x-ray dye study, despite his history of four thyroglossal duct cyst excision and revision. He presently complained of tenderness and drainage through the wound site. He was assessed with sinus tract of the neck to base of the tongue. He was scheduled for a re-excision in January 1978, but it was cancelled due to further work-up and probable need for general anesthesia. The Veteran was discharged to duty without limitations at that time. A February 1978 medical board report shows that the Veteran was assessed with thyroglossal duct cyst, sinus, recurrent, which existed prior to enlistment and which had not been aggravated by service. It was noted that the Veteran had been evaluated and treated for draining of cyst on the anterior neck. He provided a previous history of surgical excision and revisions prior to enlistment. During his shipboard duties, the Veteran experienced recurrent drainage with an inability to control the drainage with any standard medical means. Surgery was suggested; however, because of the previous four operations the chance of vocal cord paralysis was also presented to the Veteran. The medical board report also shows that current physical examination revealed no abnormalities, except for mucoid sinus tract in an anterior neck scar. No hypolargygneal abnormalities were observed. It was noted that the Otolaryngology Department opined that the Veteran "is suffering from a sinus tract in the anterior neck secondary to an operation which was performed prior to enlistment. At the present time, he does not wish to have surgery for correction of this difficulty." In conclusion, the medical board examiner stated that "it is the opinion of the Board that the [Veteran] is not fit for active duty to a physical disability which was neither incurred in or aggravated by a period of active service." The Veteran was ultimately discharged from service due to his sinus tract condition. The available post-service treatment record starting in 2008 show complaints of upper respiratory infections. See VA treatment records dated in February 2008 and October 2008. These records also note that the Veteran has a residual scar on his neck from his previous thyroglossal duct cyst excision and revisions. It was also noted that the Veteran had a history of tobacco use of half a pack a day for the last twenty years. None of these available records indicated that the Veteran's pre-existing thyroglossal duct cyst with sinus tract to base of tongue was aggravated by his period of service. Private treatment records from Connecticut Multispecialty Group dated from 2011 to 2012 show no complaints of nasal discharge, sore throat or other respiratory or otolargngeal problems. In February 2012, the Veteran was afforded a VA examination in conjunction with his claim. The examination report shows that the examiner reviewed the claims folders, including the service treatment records, and recorded the Veteran's reported medical history and the findings from clinical examination. The Veteran reported a history of thyroglossal duct surgery to remove growths when he was ages 2, 12, 13, and 14. He denied any surgery since then, but he has continued to experience post-operative sinus track that drains from his throat to his neck. The Veteran further stated that he felt that his condition was aggravated during his period of service because of his naval duties that involved sanding paint on ships for two months. He also reported having sinus tract infections which required antibiotics. He currently complained of constant post-nasal drip and drainage which drains through the fistula on his neck. He denied receiving any antibiotics for several years for a sinus infection. The February 2012 VA examination report shows that the Veteran reported that he has had symptoms of chronic sinusitis. Physical examination revealed that the sinuses were nontender, the oropharynx was unremarkable, and on the mid-anterior of his neck was a visible sinus tract with clear, white drainage with cough. A diagnosis of status post excision of thyroglossal duct cyst with revisions. The examiner noted that there was no evidence to support a diagnosis of chronic sinusitis in the claims folders or from the findings on clinical examination. The examiner further noted that there was evidence of sinus tract involvement from prior thyroglossal duct surgery that occurred prior to his enlistment into service, but the examiner concluded that there was no evidence to support that this condition was aggravated by his military service. Initially, the Board notes that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. Clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). VA's Office of General Counsel has issued a precedent opinion holding that in order to rebut the presumption of soundness in 38 U.S.C.A. § 1111, VA must demonstrate by clear and unmistakable evidence both that the disease or injury in question existed prior to service and that it was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. In this case, the evidence of record shows that the Veteran reported that he had undergone at least four surgical operations for thyroglossal duct cyst excision and revision prior to his enlistment into service. Most significantly, his June 1977 enlistment medical history report shows he reported a previous surgical history of thyroglossal duct cyst and his enlistment physical examination report noted a residual scar on his neck from the thyroglossal duct cyst excision. Consequently, the Board finds that the Veteran's enlistment demonstrates that he was not in sound condition at induction with respect to residual of excision of thyroglossal duct cyst, and thus he is not entitled to the presumption of soundness as to that condition. 38 U.S.C.A. § 1111; see also Paulson v. Brown, 7 Vet. App. 466, 468 (1995). Therefore, the issue in this case is whether the Veteran's residual of excision of thyroglossal duct cyst was aggravated by his period of service as contemplated by 38 U.S.C.A. § 1153. In this regard, the Board must first consider whether the evidence of record shows that the Veteran's condition increased in severity during his period service. Shortly after the Veteran's entrance into service, his service treatment records show he complained of tenderness and recurrent drainage through wound site of the thyroglossal duct excision. Surgery revision was recommended, but the Veteran declined further surgical intervention because of the increased risk of vocal cord paralysis. At the time of his separation from service, physical examination revealed no abnormalities, except for mucoid sinus tract in an anterior neck scar. The Veteran was ultimately discharged from service due to his sinus tract condition. Given the Veteran's subjective complaints, the Board concludes that there is at least sufficient evidence of an increase in symptomatology so as to resolve doubt and give rise to a presumption of aggravation. Therefore, the next consideration is whether there is clear and unmistakable evidence establishing that such increase was either temporary or not beyond the natural progress of the preexisting thyroglossal duct cyst excision with sinus tract from neck to base of tongue. The Board again acknowledges the service treatment records corroborated the Veteran's lay assertions that he experienced sinus tract infections associated with his exposure to heavy dust and paint chips from sanding on naval ships. However, the evidence clearly and unmistakably demonstrates that the in-service sinus tract infections only reflect a temporary flare-up of his pre-existing thyroglossal duct cyst excision with sinus tract to base of tongue and do not demonstrate a permanent aggravation beyond the natural progression of the disease. Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Thus, "a lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently is required. Routen v. Brown, 10 Vet. App. 183, 189 (1997); Verdon v. Brown, 8 Vet. App. 529, 538 (1996). In this regard, at the time of his separation from service, he received a normal physical examination except for mucoid sinus tract in an anterior neck scar and the February 2012 VA examiner concluded that there was no evidence in the claims folder or from the clinical evaluation that revealed findings of current chronic sinus disorder other than his pre-existing status post thyroglossal duct cyst excision and revision. Moreover, both the February 1978 service medical examiner and the February 2012 VA examiner found that the Veteran's period of service did not aggravate, or cause the permanent increase in his pre-existing thyroglossal duct cyst. The Board concludes that these medical opinions constitute clear and unmistakable evidence so as to rebut the presumption of aggravation in this case. See Laposky, 4 Vet. App. at 334; see also Akins, 1 Vet. App. at 232. The Board notes that there are no medical opinions of record to the contrary. The Board has considered the Veteran's own assertion that his pre-existing thyroglossal duct cyst was aggravated by his in-service exposure to heavy dust and paint chips. The Board finds that the Veteran's assertions as to etiology of his medical condition are afforded little probative weight in the absence of evidence that the Veteran has medical training that can provide the expertise to render opinions about medical matters. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Where the determinative issue involves a medical opinion, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical etiology do not constitute competent medical evidence, when the question involving etiology goes beyond mere observations. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting that a veteran is competent to provide a diagnosis of an observable condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In this regard, the consideration of whether his pre-existing thyroglossal duct cyst was permanently worsened beyond the natural progression of the disease is a matter of internal medicine that requires medical expertise. As such, the Veteran's statement that his pre-existing thyroglossal duct cyst was permanently worsened as a result of his period of service is of no probative value. Here, the record contains medical evidence that clearly establishes that the Veteran's pre-existing thyroglossal duct cyst with sinus tract was not permanently aggravated as a result of his period of service. Specifically, this medical evidence is found in the February 2012 VA examiner's medical statement, which demonstrates that there was no evidence of a permanent increase in the Veteran's pre-existing thyroglossal duct cyst with sinus tract by his period of service. Other than the Veteran's assertions, there is no evidence of record that indicates that his pre-existing thyroglossal duct cyst was aggravated by his service. In short, the preponderance of the competent evidence of record is clearly against a finding that the Veteran's pre-existing thyroglossal duct cyst was aggravated by his second period of service. See 38 C.F.R. § 3.306(b). The Board next notes that the evidence of record does not demonstrate that the Veteran has any other current sinus disorder that is related to his period of service. Although the service treatment records show that the Veteran was treated for a sinus tract infections, there is no diagnosis of or treatment for chronic sinusitis. In fact, the Veteran has not identified or produced any evidence, medical or otherwise, that would tend to show that he currently has chronic sinusitis that is related to service, to include exposure to dust and sand therein. See Sanchez-Benitez v. Principi, 259 F.3d 1356 (2001). Rather, the February 2012 concluded that there was no evidence in the claims folder or from the clinical evaluation that revealed findings of chronic sinusitis. While the February 2012 VA examination report shows that the Veteran complained of symptoms consistent with sinusitis, such as headaches and episodes of sinusitis, a review of the medical evidence and findings from clinical evaluation did not support a diagnosis of chronic sinusitis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As noted, the record does show that the Veteran has been diagnosed with COPD. See the February 2012 VA examination report. In addition, the Board concedes that the Veteran had in-service exposure to heavy dust and paint chips from sanding, and that it is not inconceivable that he was exposed to asbestos as well. However, the preponderance of the competent evidence of record is against a finding that the Veteran's COPD is related to his period of service. While the service treatment records show that he was treated for sinus tract infections, none of these records demonstrates that he was treated for or diagnosed with COPD. Moreover, the first medical evidence of a diagnosis of COPD comes from the February 2012 VA examination report, which comes more than four decades after his separation from service. The evidence of record does not support the finding that the Veteran's COPD had an onset in service or within the first year after his separation from service. 38 C.F.R. §§ 3.303, 3.307. 3.309. In addition, the record lacks any medical evidence that links the Veteran's COPD to his period of service. Rather, the February 2012 VA examiner opined that it was less likely than not that the Veteran's current respiratory condition, to include COPD, was related to his period of service. The examiner supported this medical conclusion by noting that a review of the claims folder did not support a finding that the Veteran's condition was incurred in or related to his period of service. There is no medical opinion to the contrary. The Veteran's assertions are the only evidence relating his current diagnosed respiratory complaints to service. However, he is not a medical professional, and therefore, his beliefs and statements about medical matters do not constitute competent evidence regarding matters that go beyond lay observation, such as etiology of internal medicine disease. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (under certain circumstances, lay person is competent to identify a simple medical condition). As noted above, the Veteran is competent to report what he has experienced, but the objective medical evidence is against his claim, and his assertions have been found to be not competent. In sum, the evidence of record shows that the Veteran's pre-existing residuals of thyroglossal duct cyst with excision and revisions existed prior to his entrance into his period of service. While the Veteran's service treatment records show that he was treated for sinus tract infections several times during his period of service, the competent evidence of record clearly demonstrates no permanent aggravation due to his period of service. The weight of the evidence is also against a finding that the Veteran has any other current sinus disorder. Even though the Board cannot ignore lay evidence of continuity of sinus tract infections since service, the Board finds that the Veteran is not competent as to the question of whether his underlying preexisting disorder was permanently aggravated beyond its natural progress in service. Thus, the Board finds that the February 2012 VA examiner's medical opinion carries far more weight, and the claims must be denied. Acquired Psychiatric Disorder The Veteran is seeking entitlement to service connection for a psychiatric disorder, to include anxiety disorder and personality disorder. The Veteran has various relevant diagnoses, to include anxiety disorder, polysubstance abuse, and antisocial personality disorder. The Veteran has also claimed to have posttraumatic stress disorder (PTSD) from a personal assault while he was stationed on a naval ship. At his November 2010 hearing, the Veteran testified regarding personal assault and harassment by other service members against him. He testified that he told "Jack Faye (ph), 2nd Class Petty Officer, Boatswain's Mate," that he refused to perform any more paint sanding and chipping duties. He testified that "I told him, I said I'm sick. I was like, I can't breathe in there, I'm getting sicker and sicker. I can't do this. There was an Ensign Herb (ph) standing about 10 feet away, and he grabbed me and he said, city boy, he said - and he put me over the side of the ship, over the dry dock and he says I'll drop you down in this hole. You get in there or I'll drop you down this hole. And the out of me...." The Veteran reported that he then went on Christmas vacation and went AWOL. His service personnel records confirm that the Veteran was on unauthorized absence from December 27, 1977, to January 13, 1978. A review of the Veteran's service treatment records shows that he received a normal psychiatric evaluation on his enlistment exam in June 1977. He sought treatment for complaints of nasal drainage problems starting in July 1977, and he continued to have similar complaints throughout of the remainder of his service. Service treatment records dated in December 1977 reflect that the Veteran was presented with complaints of stress, feelings of too much pressure, and feelings of imminent danger or violence. These service treatment records reflect that the Veteran described "crewmembers pushing him & not caring," that he "[f]eels like everyone is out to get him, that no one is there to help him," and that he "is experiencing conflict and lost [sic] of stress from persons he is working with and especially 3 petty officers." He also reported that he felt like he was about to "crack out" and "flip out" from the pressure he felt. These records also indicate that the Veteran had numerous self-inflicted scratches on both arms. He was counseled on alternative aways of dealing with aggression, explosiveness, responsibility and consequences. He was assessed with explosive personality disorder, moderate, not disqualifying at that time, as well as occupational discontent. He was considered fit for full duty and advised to continue to receive counseling. The Veteran was medically discharged from service in February 1978 for his status post thyroglossal duct cyst excision and revision, with sinus tract. The February 1978 medical board report shows that physical examination at that time revealed no abnormalities, except for mucoid sinus tract in an anterior neck scar. The earliest post-service treatment records associated with the claims file that reflects mental health symptoms are dated in 2007. At that time, the Veteran reported experiencing panic-type episodes which occurred in association with recent stressors involving the courts. He also reported having experienced similar symptoms several years before while going through a divorce. Subsequent VA treatment records show continued treatment for anxiety disorder and history of polysubstance abuse. In February 2012, the Veteran underwent a VA psychiatric examination. The examination report shows Axis I diagnoses of anxiety disorder and polysubstance abuse, and an Axis II diagnosis of antisocial personality disorder. The examiner found that a review of the claims folder revealed documentation of behavioral problems that predated the Veteran's period of service and resulted in the diagnosis of Explosive Personality disorder during his period of service. The VA examiner concluded that it was less likely than not the Veteran's mental health condition was causally related to his period of service or any specific events occurring during his naval service. The examiner opined that it was more likely than not that the Veteran's condition was pre-existing and there was insufficient evidence to conclude with 50/50 or greater probability that the condition was appreciably aggravated by his period of service beyond the natural progress of the disease. The examiner further stated that "if the Veteran's claimed respiratory condition was service-related, then it could be concluded with 50/50 probability that this condition aggravated the anxiety portion of his pre-existing psych condition." In February 2012, the Board sought a VHA medical advisory opinion in order to determine whether any of the Veteran's current diagnosed psychiatric disorders were related to his period of service. An April 2013 VHA medical expert opinion has been associated with the claims folder. The medical examiner noted that she had conducted a thorough review of the claims folder in conjunction with the medical opinion report. In the report, the medical examiner noted that the Veteran's current diagnoses included: Polysubstance Dependence, in partial remission, and Antisocial Personality Disorder. The medical examiner noted that there was no adequate evidence to support a diagnosis of Anxiety Disorder at that time. The examiner supported this medical conclusion by noting that none of the private treatment records from the Connecticut Multispecialty Group contain complaints of anxiety or depression, and that the Veteran's reports of anxiety symptoms at the February 2012 VA examination were subjective complaints and not supported by objective findings. The medical examiner concluded that it was less likely than not that the Veteran's personality disorder or substance disorder is related to his period of service. With regard to the Veteran's Personality Disorder, the medical examiner then stated that there was clear and unmistakable evidence that the Personality Disorder pre-existed his entry into service and was clearly and unmistakably not aggravated by his period of service. The examiner further concluded that it was less likely than not that the personality disorder were related to any injury, disease or event in service, to include subject to any superimposed injury or disease. The examiner noted that the Veteran's mental health treatment as well as his misconduct is very common patterns among service members with personality disorders. It is common for people with personality disorders to have the misperception that they are being "abused" or "harassed". They frequently go on unauthorized absences due to not wanting to do their job, while their co-workers seem to handle the same tasks without difficulty. Antisocial personality disorder, in particular, included traits of irresponsibility, as indicated by repeated failure to sustain consistent work behavior and deceitfulness for personal profit or pleasure. The medical examiner then concluded that based on a review of the record, it is unlikely that the Veteran's duties were making him sick, and more likely that he simply did not want to do them. The medical examiner stated that her medical conclusion was supported by DSM-IV and other professional guidelines as well as a review of the Veteran's claims folder. PTSD The Veteran has claimed to have posttraumatic stress disorder (PTSD) from a personal assault while he was stationed on a naval ship. VA has conceded that the Veteran suffered a personal assault according to his lay assertions, which are corroborated by his service personnel records that show he went AWOL from his duty station. See January 2012 memorandum on PTSD stressor corroboration. Service connection for PTSD requires: (1) medical evidence establishing a diagnosis of the condition pursuant to 38 C.F.R. § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); (2) credible supporting evidence that the claimed in-service stressors actually occurred; and (3) a link, established by medical evidence, between the current symptomatology and the claimed in-service stressors. 38 C.F.R. § 3.304(f). Here, first and foremost, there is no evidence of a current diagnosis for PTSD. Regardless of whether there is evidence that confirms the Veteran alleged inservice stressor, there is in fact no competent medical evidence that shows a current diagnosis of PTSD. None of the VA or private treatment records reflects that the Veteran has or had a diagnosis of PTSD. The report of the February 2012 VA psychiatric examination reflects Axis I diagnosis of Anxiety Disorder. There is no medical evidence of record that shows a diagnosis of PTSD. One of the requirements for service connection is competent evidence that a claimed disability currently exists. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Without a current medical diagnosis of PTSD, VA cannot grant an award of service connection. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Personality Disorder and Acquired Psychiatric Disorder Other Than PTSD Initially, the Board observes that the December 1977 service psychiatric consultation report shows a diagnosis of Explosive Personality Disorder. This is not a diagnosis of a psychiatric disease, but rather a personality disorder. Congenital or developmental defects, refractive errors of the eye, personality disorders, and mental deficiency, are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c); see also, Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003) (upholding VA's regulation that a congenital disorder is not a disease or injury as contemplated by 38 U.S.C.A. §§ 1110, 1131). Service connection may be granted for congenital diseases, as opposed to congenital defects. See 38 C.F.R. § 3.303(c); VAOPGCPREC 67-90, VAOPGCPREC 82-90. VA regulations specifically prohibit service connection for congenital or developmental defects unless such defect was subjected to a superimposed disease or injury during service which created additional disability. See VAOPGCPREC 82-90. Here, the Board concludes that the most probative evidence weighs against a finding that a personality disorder was subject to a superimposed disease or injury during service, or was otherwised aggravated by service. The Board acknowledges the Veteran was seen by a psychiatrist in service for mental health problems, but he was never hospitalized for any psychiatric disease or sought subsequent mental health treatment until decades after his separation from service. Moreover, the finding that the Veteran was fit to return to active duty after this psychiatric consultation weighs against his contentions that he suffers additional disability due to a superimposed injury or incurrent mental health problem during service. The lack of any continuous treatment for mental health problems over the three decades following service, also weighs against a this contention. Moreover, there is no evidence that he sought continuous treatment until 2008, when he initiated his claim for VA compensation benefits. Moreover, and most importantly, the April 2013 VHA medical examiner concluded that the evidence of record clearly and unmistakably demonstrated that the Veteran's personality disorder was not aggravated his period of service, to include as a result of a superimposed injury. There is no contrary medical opinion of record. There is no evidence of a worsening that existed at the time of separation or of growing worse in severity since the time of separation. Routen v. Brown, 10 Vet. App. 183, 189 (1997); Verdon v. Brown, 8 Vet. App. 529, 538 (1996). In short, the evidence of record is against a finding that a personality disorder increased in severity during service. To the extent that the Veteran's lay statements can be interpreted as evidence that there was an increase in severity in the personality disorder resulting from a superimposed disease or injury in service, the Board finds he is not competent to diagnose a psychiatric disorder or to assess that he incurred an additional disability as the result of his service. In this regard, the Board observes that laypersons are competent to report what comes through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). However, he is not competent to diagnose a psychiatric disorder, to include aggravation of a personality disorder. In this regard, the Board observes that there is no indication that the Veteran, as a layperson, has the requisite knowledge to diagnose a psychiatric disorder, to include aggravation of a personality disorder. Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, he is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As diagnosing a psychiatric disorder is complex in nature, the Board finds that the Veteran is not competent to diagnose an acquired psychiatric disorder, to include aggravation of a personality disorder. Moreover, the April 2013 VHA medical examiner's opinion weighs heavily against the Veteran's claim. There is no other evidence of record that suggests that there was a superimposed disease or injury during the Veteran's period of service which resulted in additional disability. In short, the personality disorder, diagnosed in service, cannot be service connected unless it was subjected to a superimposed disease or injury during service which created additional disability. There is, however, no evidence showing that the personality disorder increased in severity to create an additional disability from his experiences during his military service. See VAOPGCPREC 82-90; Terry, 340 F.3d at 1384. The Board has also considered whether service connection for a psychiatric disorder other than PTSD or personality disorder, is warranted. Here, based on a review of the evidence, the Board finds that the preponderance of the evidence weighs against the Veteran's claim. While the record shows that the Veteran underwent the December 1977 psychiatric consultation during his period of service and that he has reported experiencing mental health problems since service, both the February 2012 VA examiner and the April 2013 VHA medical examiner concluded it was less likely than not that the Veteran had a current psychiatric disorder related to service. In fact, the April 2013 VHA medical examiner questioned whether the Veteran had a current diagnosis of anxiety disorder. The April 2013 VHA medical expert supported her medical conclusion by referencing the DSM-IV and other professional guidelines. Both the 2012 and 2013 medical opinions were based on a review of the reported history, clinical interview, and the findings from the February 2012 examination as well as a review of the claims folder. There is no medical opinion of record to the contrary. The record also does not show a continuity of symptomatology (or treatment) for any psychiatric disorder, following separation from the Veteran's service in 1977 until 2007. This medical evidence comes well beyond the first year after the Veteran's discharge from his period of service. See 38 C.F.R. § 3.307, 3.309. This lengthy period without treatment for related conditions is evidence against a finding of continuity of psychiatric problems since service, and it weighs heavily against a claim for service connection on a direct basis. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). Moreover, the Veteran has not asserted that he has continuously experienced mental health symptoms since his period of service. For these reasons, the Board is denying the claim for service connection for a psychiatric disorder, to include personality disorder, PTSD and anxiety. The preponderance of the evidence is against this claim, and under these circumstances, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Headaches, Hypertension, Colon Disorder and GERD VA treatment records note that the Veteran is being treated for hypertension for GERD, and he underwent a partial colectomy for sigmoid diverticulitis. The Veteran has also competently testified to experiencing headaches. The service treatment records do not show that any of the Veteran's conditions had an onset during service. The first medical evidence of his hypertension, headaches, colon disorder, and GERD comes well after his period of service. The competent evidence of record does not demonstrate that the Veteran's conditions had an onset during his periods of service, at separation or until a decade after his separation from service. 38 C.F.R. §§ 3.303, 3.307, 3.309. In addition, the clinical evidence does not reflect, nor has the Veteran's provided lay statements to the effect that he has experienced symptoms of hypertension, GERD, colon disorder or headaches since service. He was treated for diverticulitis in 1989 and again in 2000, he was not diagnosed with hypertension until 2004, and his medical records fail to reflect complaints of headaches or GERD until after he filed his claim in 2008. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (to the effect that service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service). As discussed above, the Veteran's service records and credible testimony do confirm that he was exposed to heavy dust and paint chips while performing his naval duties. The remaining questions on appeal are whether the competent evidence of record is at least in equipoise that his hypertension, headaches, colon disorder, and GERD are etiologically related to his period of service, to include his in-service exposure to heavy dust and paint chips. None of the private or VA treatment records links his hypertension, headaches, colon disorder, and GERD to his inservice exposure to heavy dust and paint chips. The February 2012 VA examiner opined against a medical nexus between the Veteran's current diagnosed disorders and his period of service, to include his in-service exposure to heavy dust and lead paint. The VA examiner supported his medical conclusion by noting that there was no evidence of hypertension, headaches, colon disorder, or GERD until well after the Veteran's period of service. The Board also finds it significant that there is no medical evidence showing that the Veteran's hypertension, headaches, colon disorder, and GERD are related to his military service, to include inservice exposure to heavy dust and paint chips. Indeed, there is an absence of post-service symptomatology until decades after the Veteran's separation from service. In addition, no medical professional has rendered an opinion relating such disorders to his period of service. The Veteran's assertions are the only evidence relating his current diagnosed disorders to service. However, he is not a medical professional, and therefore, his beliefs and statements about medical matters do not constitute competent evidence regarding matters that go beyond lay observation, such as etiology of internal medicine disease. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (under certain circumstances, lay person is competent to identify a simple medical condition). As noted above, the Veteran is competent to report what he has experienced, but the objective medical evidence is against his claim, and his assertions have been found to be not competent. Regarding the Veteran's argument that his disorders are all secondary to his sinus disorder or his psychiatric disorder, to the extent that those claims are denied, there is no basis to warrant entitlement to service connection on a secondary basis. See 38 C.F.R. § 3.310. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for hypertension, headaches, colon disorder, and GERD. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that the claims for service connection must be denied. ORDER Entitlement to service connection for sinus condition is denied. Entitlement to service connection for respiratory condition is denied. Entitlement to service connection for acquired psychiatric disorder, to include anxiety and PTSD, is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for headache disorder is denied. Entitlement to service connection for colon disorder and GERD is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs