Citation Nr: 1327448 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 99-14 361 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a psychiatric disorder, claimed as secondary to the service-connected asthma. REPRESENTATION Appellant represented by: Jonathan Bruce, Esq. WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from August 1977 to November 1977 and from April 1981 to April 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 1999 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico that in relevant part denied the Veteran's request to reopen a claim of entitlement to service connection for a psychiatric disorder, claimed as secondary to asthma. During the course of the appeal the file was transferred to the RO in Waco, Texas, which is currently VA's Agency of Original Jurisdiction (AOJ). The Board issued a decision in January 2001 that reopened the claim of service connection and remanded the case to the AOJ for development of the merits. The Board subsequently remanded the case to the AOJ for further development in September 2003 and March 2006. The Veteran testified before the RO's Decision Review Officer (DRO) in July 1999 and November 2006. Transcripts of those hearings are of record. In May 2010 the Board issued a decision that in relevant part denied service connection for a psychiatric disorder. The Veteran thereupon appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). The Court issued an Order in March 2011 granting a Joint Motion for Partial Remand of the Parties (Joint Motion) that vacated the Board's decision regarding the claim for service connection. In October 2011 the Board remanded the case to the Originating Agency for actions in compliance with the Court's Order. The file has now been returned to the Board for further appellate review. The Veteran's representative submitted a letter to the Board in July 2013 that constitutes a claim on behalf of the Veteran for award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). The RO issued a rating decision denying TDIU in April 2006 but has not adjudicated the issue since then. Accordingly, the issue is not before the Board, and the Board does not have jurisdiction over it. The issue of entitlement to TDIU is accordingly referred to the RO for appropriate action. FINDINGS OF FACT 1. A psychotic disorder was not shown during service or to a compensable degree within the first year after discharge from service. 2. A psychiatric disorder was not manifested during service or etiologically related to service, and such disorder is not caused or permanently worsened by service-connected disability. CONCLUSION OF LAW A psychiatric disorder was not incurred in or aggravated by service and was not proximately caused or aggravated by service-connected disability, nor may incurrence in service of a psychotic disorder be presumed. §§ 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307. 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2011), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2011), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. The Board's decision in May 2010 found VA's duties to notify and assist had been satisfied. The most recent Joint Motion for Partial Remand in March 2011, as incorporated by the Court's Order, expressed no issues regarding duty to notify. The Board is confident that if any such VCAA defects had existed in its May 2010 decision, such defects would have been brought to the Court's attention in the interest of judicial economy. In regard to the duty to assist, the Court's Order asserted the Board had relied on an inadequate medical opinion, in that the August 2009 VA medical examination report did not provide a rationale for the conclusion reached (i.e., the conclusion that the claimed psychiatric disorder was not caused by or a result of the service-connected asthma). The Board accordingly remanded the case back to the same VA examiner for an addendum opinion with supporting rationale, which was accomplished in January 2012. The Board has reviewed the addendum examination report and finds the RO substantially complied with the requirements of the Board's remand. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Joint Motion for Partial Remand asserted no other deficiencies in the Duty to Assist. Neither the Veteran nor his representative has made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and neither has argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced the appellant in the adjudication of his appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Applicable Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, or continuity of symptomatology establishes the disease was incurred in service. 38 C.F.R. § 3.303(b), (d). Service connection may be presumptively granted for psychosis that becomes manifest to a compensable degree within the first year after discharge from service, even if not shown during service. 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The second and third elements may be established by showing continuity of symptomology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Service connection may also be granted for disability that is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). During the pendency of this claim 38 C.F.R. § 3.310 was amended effective October 10, 2006, in order to more thoroughly reflect the holding in Allen v. Brown, 7 Vet. App. 439, 448 (1995), that secondary service connection is available for chronic aggravation of a nonservice-connected disorder. Under the revised § 3.310(b) the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service- connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule of Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity due to the natural progress of the disease from the current level. Generally, when a veteran contends that a service-connected disorder has caused or aggravated a secondary disability, there must be competent medical evidence of such causation or aggravation. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995); Jones v. Brown, 7 Vet. App. 134 (1994). To prevail on the issue of secondary service causation, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, supra. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor involves consideration of whether the opinion is supported by a reasoned analysis. When there is a proximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence The claims folder does not include any records from the Veteran's first period of active duty. His examination for enlistment in May 1980 reveals his psychiatric evaluation was normal. On his Report of Medical History in May 1980 he denied any history of depression, trouble sleeping, or nervous trouble. Service treatment records do not include any references to psychiatric symptoms. On his March 1984 Report of Medical Examination his psychiatric evaluation was normal. March 1984 service treatment records however documented exercise induced asthma. A VA examination report signed in October 1984 noted normal findings on psychiatric evaluation. The first indication of a mental health disorder of record consists of a July 1986 consultation note to VA psychiatry stating that the Veteran's symptoms were out of proportion with his pulmonary function test (PFT). The Veteran had appeared to be very anxious. In August 1986 the Veteran presented to a VA provider complaining of irritability, anxiety and stress due to a supervisor at work. He also referred to frequent verbal arguments with his wife and poor impulse control. He endorsed impulsive, aggressive behavior and a series of stressors since May 1986, including preoccupation about his skin condition and an asthma condition in his 9-month old baby girl. He reported having done violence to property on three occasions while under the influence of alcohol; he also reported marital disharmony and depressed mood. He initially did not want to take medication but later decided to take Librium. The clinical impression was rule out (R/O) impulse control disorder with somatizations. The Veteran was referred for vocational rehabilitation since his mental condition was not conducive to a continued career in law enforcement. In September 1986 the Veteran's wife requested psychiatric treatment for the Veteran because he was reportedly having problems at home and at work. His problems at work involved altercations with co-workers as well as "on the street." She stated the Veteran had recently started treatment with a private psychiatrist. VA treatment notes dated in October 1986 show the Veteran was referred to the mental health clinic by the vocational rehabilitation department. The Veteran denied recent use of alcohol but admitted an incident in September 1986 in which he had used "excessive force" while making an arrest; the incident was currently under investigation. However he was feeling better, functioning better and had a change of supervisor at work. The clinical assessment was R/O generalized anxiety disorder (GAD) versus impulse control disorder. In November 1986, a VA clinical psychologist evaluated the Veteran including administering a battery of tests. The Veteran reported that when problems occurred at work he would become desperate, then annoyed, and then would manifest physical symptoms. The conclusion was the Veteran had a severe anxiety disorder. The Veteran was noted to have poor tolerance for conflictual, stressful and problematic situations and to quite often resort to somatizations. A December 1986 letter by the Veteran's employer at the Police of Puerto Rico (Cayey District) states the Veteran had been having difficulty at work due to itching, watery eyes and asthma. He also appeared to be mentally and emotionally affected, having to be continually reminded and instructed regarding his work requirements. Records from the VA Mental Hygiene Clinic (MHC) dated in January 1987 reveal the Veteran reported numbness in both lower extremities. He had been placed in a less stressful place by his supervisor and his wife was more cooperative. He felt his physical condition had deteriorated. The assessment was somatic complaints, and the Veteran was referred to internal medicine. In February 1987 the Veteran complained of job-related stress caused by arresting people. In March 1987 the Veteran reported plans to start a small business; he was still working at the police department but had been placed in a job that allowed him to work on his own. In April 1987 he complained his former supervisor had interfered with his plans to start a business; the clinician noted multiple somatic complaints and depressed mood. November 1989 VA records reveal the Veteran was sad, had problems falling asleep and was recently separated from his spouse. A follow up note includes diagnostic impressions of a GAD and marital problems. In November-December 1989 the Veteran was hospitalized at VA for treatment of psychiatric symptoms. At admission he was depressed, irritable, hostile, lacked appetite and felt sad. Prior to admission he had been hearing voices. Schizophreniform disorder was diagnosed in Axis I (clinical disorder). During inpatient treatment he was coincidentally treated for shortness of breath due to the service-connected bronchial asthma. Axis III (general medical conditions) listed chronic bronchial asthma, irritable bowel syndrome and status post left knee trauma. A VA medical certificate in September 1990 showed current diagnosis of adjustment disorder and borderline personality versus intermittent explosive disorder, while a VA medical certificate in March 1991 showed an impression of recurrent-type major depression. In March 1991 a VA MHC treatment note recorded clinical impression of R/O schizophrenia and R/O borderline personality disorder. An MHC note dated in September 1991 states the Veteran was doing better because he had found a job, but he continued to ventilate feelings about the way he had been treated by the police department, his former employer. The Veteran was treated at the Hospital of San Juan Capistrano in June 1998 for severe major depression (Axis I). Bronchial asthma was noted in Axis III. Records from the First Hospital Panamericano indicate the Veteran was admitted in March 1999, with severe depression and history of a recent suicide attempt, having been recently left by his romantic partner. A history of very explosive behavior was also noted. The Veteran's principal complaint was that he had problems but did not know if they were from the medications for his asthma. His acute stressors were the breakup with his girlfriend, family problems and a car accident. The final diagnosis was major depressive disorder with psychotic features and intermittent explosive disorder (Axis I). Also noted in the diagnosis was paranoid features (Axis II) and sinusitis, bronchial asthma and dermatitis (Axis III). An April 1999 letter from the veteran's private physician, Dr. Prieto-Agostino reads in pertinent part, as follows: His mental condition has several precipitating factors such as chronic bronchial asthma, problems with his work environment and problems with his primary support group. His mental treatment is not due to the use of alcohol or illegal drugs. Due to the many medications ordered by doctors for his asthma condition, he has drastic changes in his state of mind, insomnia, high level of anxiety and irritability. These symptoms are described in the literature of those medications and stated clinically by this patient. The Veteran testified before the RO's Hearing Officer in July 1999 that his psychiatric problems to include lack of impulse control were due to excessive medication for his service-connected asthma, and that this had been confirmed by his private psychiatrist, Dr. Prieto-Agostino. The Veteran received inpatient treatment at San Juan Capistrano Hospital in June 2001; his diagnosis was recurrent major severe depression (Axis I) and bronchial asthma (Axis III). A June 2001 treatment note by Dr. Juan C. Candelario Lanza characterizes the Veteran as having a history of bronchial asthma, eczema, allergic rhinitis, conjunctivitis, sinusitis and depression, being referred for exacerbation of his respiratory disorder. In a June 2001 letter, Dr. Prieto-Agostino stated the Veteran had difficulty controlling his asthma due to dusty, humid condition in his workplace. In relevant part, Dr. Prieto-Agostino wrote as follows: The increasing on medications for treating his frequently asthma episodic cause a severity in depression symptoms. He presents more insomnia, lack of energy, high energy, impulsive, a high level of anger, and suicidal thoughts. A July 2001 psychiatric evaluation was performed as part of a disability determination; the examiner was private psychiatrist Dr. Jose E. Berrios-Merced. The Veteran's primary complaint was that he could not tolerate his asthma illness. Dr. Berrios-Merced noted medical history significant for bronchial asthma, sinusitis, conjunctivitis, allergy and eczema. Dr. Berrios-Merced performed a mental status evaluation (MSE) and noted clinical observations in detail. The diagnosis was moderate-to-severe recurrent major depression without psychotic features. A second psychiatric evaluation was ordered by the Postal Service in August 2001 and performed by Dr. Marina Sanz. The Veteran had been accommodated with flexible working conditions since April 2001 due to his physical and emotional conditions (chronic sinusitis, bronchial asthma and depression). The Veteran reported depression since 1983. He stated he had worked as a police officer but was "disarmed" due to emotional problems and then began working at the post office. Dr. Sanz diagnosed major depression severe with psychotic features. Dr. Sanz noted the Veteran as unable to continue working due to concentration, tolerance and inability to handle minimally stressful situations, with poor self-control and hostile feelings against supervisors. The report is silent in regard to any association between the Veteran's psychiatric symptoms and his medications for asthma. A "case development sheet" dated in August 2001, characterizes the Veteran as a person with a history of severe asthma who had referred for depressive symptoms, insomnia, anger and suicidal thoughts. The current working diagnosis of major depression was continued. In October 2001 the Veteran was examined by a VA psychiatrist who reviewed the claims file and noted the Veteran's psychiatric history in detail. Thereafter, as part of the examination process, the Veteran received a VA Social and Industrial Survey in November 2001, which was reviewed by the VA examiner and considered in an addendum report issued in December 2001. The addendum report includes the following opinion: Before we render a final diagnosis we want to clearly state the fact that this Veteran's neuropsychiatric condition is not secondary in any way to his service-connected bronchial asthma. As we clearly explained in the report of 10-12-01, from the very beginning when this Veteran started to receive psychiatric treatment, it was secondary to marital and family problems that he experienced. What we do find is that when this Veteran becomes emotionally affected, this does appear to affect his condition of bronchial asthma, in terms of having exacerbations of this condition. The examiner diagnosed recurrent major depression. In May 2003 the Veteran was examined by private psychiatrist Dr. Luis Carlos Rojas Ruiz, on referral for disability evaluation by the Social Security Administration. The Veteran reported having to leave the post office because of conflict with his supervisor, who would not accommodate the Veteran's asthma problems. Dr. Ruiz performed an MSE and noted observations in detail. The resultant diagnosis was schizo-affective depressive disorder with recurring persecutory deliria. Also in May 2003, the Veteran was treated by private pulmonologist Dr. Rogelio Gonzalez for allegations of asthma, sinusitis and depression. Dr. Gonzalez noted the Veteran's respiratory symptoms in detail and entered a diagnosis of bronchial asthma, allergic rhinitis, pansinusitis and depressive and aggressive disorder. The Veteran had a VA psychiatric consult in September 2004 that resulted in diagnoses of depressive disorder NOS, R/O dysthymia, R/O major depressive disorder (MDD) in Axis I. Medical problems of asthma and gastritis were noted in Axis III. VA psychiatric treatment notes dating from October 2004 to April 2005 show diagnosis of GAD. Thereafter, psychiatric treatment records through September 2006 show symptoms and continued treatment with medications but do not record a specific diagnosis. The Veteran testified before the RO's Decision Review Officer (DRO) in November 2006 that he had lost his job, his family, and everything else due to the service-connected asthma, which made him feel bad. He also stated that the medications he had been taking for asthma over the years affected him physically and mentally. The Veteran subsequently sought treatment for his psychiatric disorder at the VA Medical Center in San Juan. In April 2007 the VA psychiatrist took the Veteran's history and recorded an assessment of major depression recurrent without psychotic features due to sequelae of asthma. Subsequent treatment notes from this provider through November 2007 show continued diagnosis of major depression recurrent without psychotic features due to sequelae of asthma, plus R/O organic affective disorder secondary to asthma medication and history of head trauma. A lengthy VA mental health history and physical note dated in September 2007 shows the Veteran presented with primary complaint of difficulty sleeping and increased depression. The Veteran reported a history of angry outbursts, the first occurring in service although his history in service was actually benign. The clinician noted depression since the Veteran moved to Texas from Puerto Rico and also noted the Veteran had been diagnosed in Puerto Rico by a VA provider as having "major depression without psychotic features due to asthma." The provider performed a mental status examination and noted observations in detail. The provider diagnosed rule out bipolar disorder, intermittent explosive disorder, mood disorder secondary to organic cause, medical condition, medication and substance abuse. The Veteran presented to the VA primary care clinic (PCC) in Dallas, Texas in May 2008 to establish care, having transferred from Puerto Rico. He reported a history of bipolar disorder. Later, the assessment was revised to note the Veteran was depressed and engaging in alcohol abuse. The Veteran's ex-wife submitted a letter in June 2008 asserting that the Veteran had been lately confused and depressed about his mental illness and his asthma. During their marriage she had observed the Veteran to hear voices and have mood swings; she stated the asthma drove him crazy and he was paranoid about not waking up breathing. The Veteran's mental disorder became progressively worse over the years, resulting in their divorce. A VA examination was conducted in August 2009, performed by a psychiatrist who reviewed the claims file and the Veteran's medical records as well. The examiner noted the Veteran's psychiatric history and also noted observations during an MSE in detail. The VA examiner diagnosed depressive disorder NOS in Axis I; no specific illness was noted in Axis III but the treatment report cited 16 medical issues, led by allergic rhinitis but including asthma plus 14 more diagnosed medical disorders. The examiner concluded that the Veteran's neuropsychiatric disorder was not caused by or a result of the Veteran's service connected asthma, including medications prescribed for its treatment, and that neuropsychiatric disorder was less likely than not permanently aggravated by the Veteran's service connected asthma. As rationale, the VA examiner wrote that careful review of the claims folder and medical records showed no evidence of psychiatric complaints, psychiatric findings, nor psychiatric treatment prior to military service, during service or within one year after discharge from service. The Veteran first sought psychiatric care in August 22, 1986, two years after his military discharge. The Board subsequently returned the file to the VA examiner who had performed the August 2009 examination cited above, requesting her to provide a more reasoned discussion of whether the Veteran's service-connected asthma had caused or aggravated the claimed psychiatric disorder. In response, the examiner issued an addendum in January 2012 affirming her previous opinion that the claimed disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As rationale, the examiner stated the Veteran sought psychiatric care in 1986, two years after discharge from service, but was gainfully employed until 2001 when he was dismissed from his job for fighting with a co-worker. The examiner stated a temporal relationship between the depressive disorder and the Veteran's service-connected physical conditions had not been established. Accordingly, the opinion expressed in the August 2009 examination report remained in effect. Analysis The Board notes at the outset that review of the file does not show a psychiatric disorder having onset in service, as also noted by the VA examiner. Further, the Veteran has not asserted such an onset. The Veteran has not asserted, and the evidence of record does not suggest, that he has an acquired psychiatric disorder that became manifest after service but is somehow etiologically related to service. Entitlement to service connection on a direct basis is accordingly not shown. Although the Veteran's psychiatric illness has been variously diagnosed, including a psychotic disorder, there is no indication of psychotic symptoms to a compensable degree within the first year after the Veteran's discharge from service. Accordingly, service connection on a presumptive basis under 38 C.F.R. § 3.309(a) is not for application. The remaining theory of service connection, and the theory consistently advanced by the Veteran, is that the claimed psychiatric disorder was caused or aggravated by a service-connected disability, in this case his service-connected asthma. As noted above, secondary service connection claims require evidence of a current disability and evidence which demonstrates a causal relationship between the current disability and a service-connected disability. See Reiber, 7 Vet. App. 513. Further, in claims based on 38 C.F.R. § 3.310, medical evidence is required to provide a nexus between a service connected disability and the currently diagnosed disorder. See Schroeder v. Brown, 6 Vet. App. 220 (1994). In this case, there is conflicting medical evidence on the question of proximal causation or aggravation. Medical evidence supporting the Veteran's theory consists of the April 1999 and June 2001 letters from Dr. Prieto-Agostino, and also the 2007 VA records that include psychiatric diagnoses as sequelae to asthma. Medical evidence weighing against the Veteran's theory consists of the VA examination reports dated in October 2001 and August 2009, with additional review opinion in January 2012. It is the Board's duty to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). As true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The probative value of medical evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri, id. Greater weight may be placed on one physician's than another's depending on factors such as the reasoning employed by the physicians and whether or not (and the extent to which) they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). However, review of the claims file, in and of itself, does not make a medical opinion more or less probative. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." Nieves-Rodriguez, 22 Vet App 295. For the reasons below, the Board finds the opinions of the VA examiners to be more probative of the issue on appeal than the contravening opinions cited above. The letters from Dr. Prieto-Agostino list bronchial asthma as a precipitating factor in the Veteran's mental condition and state his medications caused "drastic changes" in his state of mind, insomnia, high levels of anxiety and irritability. There is nothing in letters indicating Dr. Prieto-Agostino was aware of or reviewed the Veteran's records from 1986 when he initially developed psychiatric symptoms, so it is unclear what "changes" are referred to versus any baseline. Also, Dr. Prieto-Agostino made no effort to list the Veteran's asthma medications and show that such medications are associated with secondary psychiatric effects. In that regard, Dr. Prieto-Agostino stated that the symptoms were described in the literature of those medications "stated clinically by this patient," which appears to indicate the Veteran told Dr. Prieto-Agostino that the literature for his medications described his symptoms rather than Dr. Prieto-Agostino reading or being familiar with the literature and concluding the Veteran's symptoms were caused by his medications. The June 2001 letter indicates only that his asthma medications cause an increase in the severity of his symptoms. Accordingly, the statement by Dr. Prieto-Agostino is conclusory; a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Some VA treatment notes dated in 2007 appear to link the Veteran's psychiatric illness with his asthma. Notably, those diagnostic impressions do not continue in the VA records from 2008 or appear in any VA records prior to 2007. As above, there is nothing in the reports where this link is indicated to show the authors reviewed or were familiar with the Veteran's medical history. Indeed, the initial history recorded shows it to have been given by the Veteran orally. While it may not be inaccurate is it clearly incomplete. Further, by the end of September 2007 one provider had changed her assessment to depression with alcohol abuse. Most significantly, there is no rationale provided for the stated impression that psychiatric symptoms were due to sequelae of asthma. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Medical evidence against the claim consists of evaluations by two different VA examiners (October 2001 and August 2009) that included complete reviews of the Veteran's medical history, examinations of the Veteran and an opportunity for the Veteran to give his history to the examiners. Both VA examiners concluded the Veteran's psychiatric disorder was unrelated to his service-connected asthma (reaffirmed in the review opinion of January 2012). Notably, the VA opinion in October 2001 stated that it was the Veteran's psychiatric disorder that was causing increased asthma symptoms, rather than the reverse as urged by the Veteran. Thus, the opinions of the VA examiners comport with the criteria for probative value cited in Nieves-Rodriguez; i.e., the providers were fully informed of the pertinent factual premises and provided fully articulated opinions that were supported by reasoned analyses. The Board acknowledges that review of the claims file, in and of itself, does not make a medical opinion more or less probative; Nieves-Rodriguez, 22 Vet App 295. Similarly, in Snuffer v. Gober, 10 Vet. App. 400 (1997), the Court indicated it had never decided that in every case a medical examiner must review all prior medical records before issuing a medical opinion or diagnosis. However, in this case, it is a clear advantage for a medical provider in articulating an opinion regarding a relationship between the claimed psychiatric disorder and the service-connected asthma to have access to the claims file, which has voluminous VA and private treatment records relating to the concurrent progress of both disorders. Given that the VA examiners had access to a greater range of relevant information, their opinions are better-informed and accordingly more probative of the specific question on appeal. In weighing the opinions the Board gives little weight to the letters from Dr. Prieto-Agostino as he offered only conclusions, with no indication of his awareness of the Veteran's full medical history. Similarly, while the VA providers in 2007 had access to the Veteran's VA treatment record, they did not have access to the private treatment records that are in the claims file, nor do the treatment records show that the psychiatric providers performed any detailed research into the Veteran's respiratory history prior to articulating their opinions. These opinions accordingly have reduced probative value under the criteria of Nieves-Rodriguez. The Board is aware and considered that asthma medications may cause side effects. For that reason, on two occasions VA evaluations and opinions were requested. Most persuasive was the contemporaneous medical record which did not reveal the Veteran's initial symptoms in 1986 were related to anxiety about his asthma; instead, at that time he was having difficulty on the job and at home. The record of his first hospitalization and subsequent treatment does not reveal a preoccupation with his asthma. It does, however, reveal the Veteran had somatization symptoms. It was his medical doctors who referred him to a psychiatrist when his symptoms of asthma were inconsistent with the results of his pulmonary function tests. In essence the diagnoses in the 2007 VA records represent only consideration of possible diagnoses, not an established diagnosis or link between the asthma and his psychiatric disorder. Those diagnoses were dropped and replaced with a diagnosis of bipolar disorder by late 2007 and early 2008. For that reason those records are of less probative value than the opinions of the VA examiners cited above. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony before the RO's Hearing Officers, his correspondence to VA and his statements to various medical providers. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). In this case the Veteran's testimony is not offered to show onset and continuity of symptoms, which is an area in which a layperson is competent to provide testimony, and indeed the onset and continuity of his psychiatric disorder is not in question. Rather, the Veteran's lay evidence is offered to establish a secondary relationship between a service-connected disability and a claimed disorder, but this is a complex medical question that is not within the competence of a layperson. Kahana, 24 Vet. App. 428. Rather, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation; see Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this case, as shown above, the most probative medical opinions of record show the Veteran's claimed psychiatric disorder is not proximately caused by or aggravated by his service-connected asthma. Based on the evidence and analysis above, the Board finds the criteria for service connection for a psychiatric disorder are not met. Accordingly, the claim must be denied. Because the evidence preponderates against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER Service connection for a psychiatric disorder is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs