Citation Nr: 1328195 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 05-18 733 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran had active service from June 1985 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, that denied service connection for a psychiatric disorder, to include PTSD (claimed as PTSD, depression, anxiety, insomnia, and addictive behavior). By way of a February 2012 decision, the Board denied the claim of entitlement to service connection for a psychiatric disorder, to include PTSD. The Veteran appealed this denial to the United States Court of Appeals for Veterans Claims (Court), and the Court in September 2012 approved a Joint Motion for Partial Remand (Joint Motion) vacating the Board's February 2012 denial of the psychiatric claim, and remanding the claim for development consistent with the Joint Motion. FINDINGS OF FACT 1. The evidence on file does not include a current diagnosis of PTSD made in accordance with the provisions of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 2. A psychiatric disorder other than PTSD was not diagnosed prior to or during active service, or for many years thereafter, it did not clearly and unmistakably exist prior to service, nor has a currently diagnosed psychiatric disorder been etiologically linked to the Veteran's period of service, or any incident therein. CONCLUSIONS OF LAW 1. PTSD was neither incurred in nor aggravated by active military service; and cannot be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304(f) (2012). 2. Service connection for a psychiatric disorder is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claim in letters dated in December 2003 and March 2009, wherein the Veteran was advised of the provisions relating to the VCAA. The Veteran was advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to the VA. The Board further observes that during the pendency of this appeal, on March 3, 2006, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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. The Veteran was provided with notice of the type of evidence necessary to establish a disability rating or effective date as was discussed in the Dingess case in May 2009, after the initial adjudication of the claim in April 2004. However, subsequent adjudication of the claim on appeal was undertaken in a supplemental statement of the case issued in July 2010. Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating claim and notifying claimant of such readjudication in the statement of the case). VA psychiatric evaluations were conducted in July 2008 and November 2009. Thereafter, the Board sought an expert medical opinion from the Veterans Health Administration (VHA) in 2011. That opinion was provided in June 2011. The Board requested additional information clarifying that opinion, which was provided in September 2011 and May 2013. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Accordingly, the Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, to include PTSD. The Veteran's service personnel records indicate that he had approximately 2.5 years of foreign and/or sea service, and was not awarded decorations evidencing combat. His occupational specialty was listed as a record telecommunications center operator. The Veteran's service treatment records are negative for complaints, treatment or a diagnosis of a psychiatric nature. A periodic physical examination report of September 1991 reflected that psychiatric evaluation was normal. It does not appear that a separation examination was conducted in conjunction with his discharge from service in December 1992. Post-service VA records reflect that the Veteran was hospitalized in July 1999 and August 1999, at which time continuous drug dependence (cocaine/cannabis) was diagnosed. A 2-year history of cocaine abuse was noted. In June 2003 and July 2003, the Veteran was again hospitalized for treatment of diagnosed continuous drug dependence, cocaine and cannabis. At that time, a 20-year history of drinking was noted. The intake report reflected that the Veteran's mother died of cancer when he was 17 years old, and that thereafter, he became depressed and began to use marijuana, crack cocaine and alcohol. It was also noted that the Veteran's father was a functioning alcoholic who died after over-ingesting alcohol. In July 2003, the Veteran filed service connection claims for a variety of conditions including depression, anxiety, PTSD, insomnia and addictive behavior. In a January 2004 stressor statement, the Veteran reported that he received a call from the Red Cross that his mother was going to die in a few days. He stated that he went home and that she passed away in February 1988 (or February 1986). He indicated that he was very close to his mother and that he never was able to fully grieve. The Veteran further reported that his father died in January 1993 from a heart attack, after he was released from his period of service. A July 2006 psychiatric evaluation reflected that bipolar disorder was diagnosed. In a June 2008 stressor statement, the Veteran attributed his psychiatric problems and addictions to the death of mother at the outset of his period of service. He also reported that his father was an alcoholic and that he had nobody to talk to about his mother's death. A VA psychiatric examination was conducted in July 2008 and the Veteran's claims file was reviewed. The examiner, a psychologist, indicated that the Veteran's primary stressor was that his mother died of cancer while he was in the military. It was noted that the Veteran was given a week of leave to attend her funeral. The Veteran also reported that his father died soon after he was discharged. The following diagnoses were made: bipolar disorder; alcohol dependence; cannabis dependence; and cocaine dependence (all in remission). The examiner indicated that the Veteran's drug and alcohol dependence were more likely than not secondary to his bipolar disorder. The examiner commented that although the Veteran did not meet the criteria for PTSD, his bipolar disorder interfered with his functioning for many years. The examiner stated that it was only after the Veteran's bipolar disorder was treated that he had been able to abstain from drugs and alcohol and develop a more stable life. The examiner indicated that "it [was] possible that the deaths of [the Veteran's] parents precipitated depressive reactions as part of the bipolar disorder and led to a decline in functioning." The examiner further remarked that "although a PTSD diagnosis [was] not supported, it [was] more likely than not that the deaths of both parents (in 1985 and 1992) aggravated [the Veteran's] bipolar disorder and precipitated depressive reactions which caused a decline in his functioning." In March 2009, the service connection claim for a psychiatric disorder was remanded for additional evidentiary development. In November 2009, another VA psychiatric examination was conducted and the Veteran's claims file was reviewed. The Veteran reported that he began drinking at the age of 12 and smoked marijuana on a daily basis during high school. He stated that he drank excessively in service, especially after his mother died and used hashish at the end of his tour of duty, but had not used any illicit substances prior to that time. Bipolar disorder was diagnosed, with related conditions described as alcohol, cannabis and cocaine dependence in sustained full remission. The examiner indicated that she thoroughly reviewed the Veteran's claims file and his electronic medical records, and that she performed a comprehensive clinical interview as well. The examiner stated that the Veteran's history, clinical course, and current presentation were most consistent with a DSM-IV diagnosis of a bipolar affective disorder, characterized by chronic symptoms of irritability, sleep disturbance, distractibility, and impulsivity. The examiner reported that the Veteran had been diagnosed with and treated for a bipolar disorder at VA facilities since June 2006. The examiner indicated that the Veteran described an extensive substance dependence history dating back to his teens and prior to enrolling in the military. The examiner related that the Veteran's substance use resulted in moderate behavioral disturbances (i.e., cheating in school as he could not concentrate on material secondary to intoxication, as well as being picked up by police on multiple occasions, although without being arrested). The examiner reported that the Veteran continued to drink while in the military. The examiner stated that the Veteran's mother died in the beginning of his tour of duty, which had a significant emotional impact on him. It was noted that the Veteran drank heavily in order to cope with his mother's death, which was a pattern that continued throughout his military service and for several years after discharge from service. The examiner indicated that the Veteran reported that his drinking and later illicit drug use and psychiatric symptoms were exacerbated following his father's death in 1992, and then following his brother's death in 2004. The examiner commented that "although [the Veteran's] parents' deaths may have potentially triggered a depressive reaction related to his bipolar disorder, it was difficult to make a firm conclusion about the etiology of his mental disorder when considering his ongoing substance dependence." The examiner also further noted that there were no records indicating treatment for a mental disorder during the Veteran's military service and that, in fact, the Veteran did not receive treatment until 2003, eleven years post-discharge, and that treatment was for his substance dependence. The examiner indicated that "there was no evidence that any events directly related to service caused or aggravated his psychiatric condition." The examiner reported that the Veteran continuously identified his parents' deaths as the stressors that were related to his psychiatric problems. The examiner remarked that although the Veteran did learn of his mother's death while in the service, that event was not considered to be connected to his period of service. The examiner commented that, thus, it was her opinion that "it [was] less likely than not that the Veteran's bipolar disorder [was] etiologically related to his period of service." The examiner stated that the death of one's parents does not meet the DSM-IV criteria for a stressor associated with PTSD. The examiner reported that while in the service, the Veteran was not in a combat zone and did not describe involvement in any other events that met the DSM-IV criteria for potentially traumatic events. The examiner indicated that, therefore, without a stressor present, there was no evidence of PTSD. In 2011, the Board sought still further evidentiary development of the Veteran's claim, requesting an expert medical opinion from VHA. In doing so, the Board observed that a March 2009 Board remand had specifically requested that the Veteran be scheduled for a VA examination by a psychiatrist to determine the etiology of any current psychiatric disorder; it was noted that the November 2009 VA psychiatric examination was performed by a psychologist. Additionally, the Board described the November 2009 VA examiner's opinions as somewhat contradictory. In this regard, it was explained that the examiner indicated that there was no evidence of PTSD and that it was her opinion that "it [was] less likely than not that the Veteran's bipolar disorder [was] etiologically related to his period of service." The Board observed that the examiner also commented that "although [the Veteran's] parents' deaths may have potentially triggered a depressive reaction related to his bipolar disorder, it was difficult to make a firm conclusion about the etiology of his mental disorder when considering his ongoing substance dependence." The Board interpreted the examiner's statement as implying that the Veteran may have had a depression reaction at the time of his parents' deaths related to his bipolar disorder and believed that this appeared to contradict her opinion that his bipolar disorder was not etiologically related to his period of service, warranting additional development. The Board requested that the medical expert review the entire record and furnish an opinion, supported by adequate rationale, with respect to the following questions: Please identify all current psychiatric disorders. For each psychiatric disorder diagnosed, please indicate whether it more likely, less likely, or at least as likely as not (50 percent probability), that any currently diagnosed psychiatric disorder is etiologically related to the Veteran's period of service. Please also comment as to the likelihood that any aspect of the Veteran's period of service caused or permanently aggravated a psychiatric condition that results in current disability. If it is determined that the that deaths of the Veteran's parents caused a chronic increase in severity in a psychiatric disorder (as opposed to a temporary reaction), the examiner should point to any evidence showing that increase was associated with the Veteran's period of service. If PTSD is diagnosed, the examiner should specify the stressor(s) upon which the diagnosis was based. In June 2011, a medical opinion was provided by a VA psychiatrist, who indicated that the four volumes of the Veteran's medical history had been reviewed. Initially, it was concluded that the Veteran met the criteria for a diagnosis of bipolar disorder and that disorders including cannabis, alcohol, and cocaine dependence were also shown. The doctor could not determine whether the diagnosis of bipolar disorder was primary or substance induced, and opined that in any event, it was less likely etiologically related to the Veteran's period of service. The psychiatrist explained that the death of the Veteran's parents appeared to be a significant negative life event that may have played a role in the exacerbation of his bipolar disorder and the co-morbid substance abuse disorder. It was further observed that there was no evidence that any event directly related to military service initiated or exacerbated his psychiatric condition. The psychiatrist concluded that a DSM diagnosis of PTSD was not established based on the specified criteria. In August 2011, additional clarification relating to the opinion was sought. Specifically, it was requested that an opinion be provided addressing: (1) whether it was at least as likely as not that the Veteran had a psychiatric disorder which pre-existed service; (2) if so, whether that disorder was chronically aggravated (permanently worsened) during military service; and (3) if not, whether it was at least as likely as not that the currently claimed psychiatric disorder was etiologically related to the Veteran's period of service. In September 2011, the psychiatrist who provided the original June 2011 opinion, provided an addendum. Initially, the psychiatrist opined that it was at least as likely as not that the Veteran had a psychiatric disorder which preexisted service. However, later in the addendum the psychiatrist explained that based on the facts (as provided below) it was "possible" that the Veteran may have had a psychiatric disorder which preexisted service, but could not conclude whether the condition was aggravated during service, due to the death of his parents. Evidence summarized by the psychiatrist included the death of the Veteran's mother when he was 18 years old and starting his military career, and the death of his father soon after the end of his military career, as well as the Veteran's reports of increased alcohol use and substance abuse associated with these deaths. Also noted was the Veteran's alcohol use from age ten and cannabis use as a teen. It was further mentioned that he had his first psychiatric admission in 1999, at which time cocaine and cannabis abuse were diagnosed, and that bipolar disorder was first diagnosed in 2006. Unfortunately, in its August 2011 correspondence, the Board requested the incorrect evidentiary burden of proof from the psychiatrist. While the Board requested a preponderance of the evidence standard (i.e., whether it was at least as likely as not [50 percent or greater probability] that the Veteran had a psychiatric disorder that preexisted service entrance), the correct standard in such circumstances involving preexisting disorders is the clear and unmistakable evidence standard. As discussed in greater detail below, clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. As such, the Board obtained an addendum opinion from the psychiatrist in May 2013. The psychiatrist explained that the Veteran "may or may not have" genetic predisposition, psychosocial stressor, childhood experience, and substance abuse that may make him vulnerable to have a psychiatric disorder. However, the psychiatrist continued that "there is no clear and unmistakable evidence that the veteran has a psychiatric disorder that preexisted service entrance, as there is no evidence in his medical record that he had a psychiatric disorder prior to his military service." The psychiatrist reiterated that it was unclear to him if the Veteran had any preexisting psychiatric disorder, and opined that it was not at least as likely as not that any current psychiatric disorder was etiologically related to or first manifested during the Veteran's period of service. To the contrary, the psychiatrist emphasized that the Veteran was not diagnosed with bipolar disorder until a decade following his discharge from active duty service. The Veteran contends that he has a psychiatric disorder, to include PTSD, which is related to his period of service. Specifically, he maintains that his psychiatric disorder resulted from the death of his mother which occurred at the beginning of his period of service, following which he received no counseling and did not grieve, compounded by the death of his father in 1993, shortly following his discharge from service. Generally, in order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may 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). Service connection shall be granted to a Veteran if the Veteran served 90 days or more during a war period or after December 31, 1946 or had peacetime service on or after January 1, 1947, and conditions including: arthritis, although not otherwise established as incurred in or aggravated by service, are manifested to a compensable degree within one year following the requisite service. 38 C.F.R. §§ 3.307, 3.309 (2012). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To the extent that the Veteran seeks service connection specifically for PTSD, service connection for PTSD in particular requires: (1) medical evidence diagnosing the condition in accordance with the American Psychiatric Association's Statistical Manual of Medical Disorders (4th ed. 1994) (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 stressor(s). See 38 C.F.R. § 1154(b); 38 C.F.R. §§ 3.304(f), 4.125(a); see also Cohen v. Brown, 10 Vet. App. 128, 137-138 (1997). The diagnostic criteria, including those related to stressors, set forth in the DSM-IV for mental disorders have been adopted by the VA. 38 C.F.R. § 4.125. The DSM-IV provides two requirements to support a diagnosis of PTSD: (1) A person must have been "exposed to a traumatic event" in which "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others;" and (2) "the person's response [must have] involved intense fear, helplessness, or horror." DSM-IV at 209; see also Cohen v. Brown, 10 Vet. App. 128 (1997). These criteria are no longer based solely on usual experience and response but are individualized (geared to the specific individual's actual experience and response). The Board further notes that effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f) relating to establishing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standards for establishing the occurrence of an in-service stressor for non-combat Veterans. See 75 Fed. Reg. 39,843-39,852 (effective July 13, 2010). These revised regulations apply in cases like the Veteran's, which were appealed to the Board prior to July 13, 2010, but not decided by the Board as of that date. 75 Fed. Reg. 41092 (July 15, 2010) (to be codified at 38 C.F.R. § 3.304(f)). The amended version of 38 C.F.R. § 3.304(f)(3) liberalizes the evidentiary standard for establishing the required in-service stressor under certain circumstances. First, the Veteran must have experienced, witnessed, or have been confronted by an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, and the Veteran's response to the event or circumstance must have involved a psychological or psycho- physiological state of fear, helplessness, or horror. 75 Fed. Reg. 39852 (July 13, 2010) (to be codified at 38 C.F.R. § 3.304(f)). Second, a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, must confirm that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor. Id. Additionally, there must be in the record no clear and convincing evidence to the contrary, and the claimed stressor must be consistent with the places, types, and circumstances of a Veteran's service. Id. Initially, a threshold requirement for the granting of service connection for PTSD under either the former or amended regulations is evidence of a current disability. In other words, in the absence of evidence of a current disability, in this matter a diagnosis of PTSD according to the DSM-IV, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Court held that the requirement in a claim of service connection of current disability "is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim." See McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, the Veteran's service treatment records are entirely negative for a diagnosis of PTSD, as are post-service clinical records. In addition, VA examination reports of July 2008 and November 2009 reflect that the diagnostic criteria for PTSD had not been met. Finally, the June 2011 medical opinion indicated that there was no evidence in the file that the diagnostic criteria relating to PTSD had been established. The law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a current disability. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Thus, because the evidence firmly establishes that the evidentiary record does not contain a current diagnosis of PTSD made in accordance with the DSM-IV, service connection for this claimed disorder is not warranted upon this basis alone. With respect to the service connection claim for a psychiatric disorder other than PTSD, initially the Board must address whether a psychiatric disorder existed prior to service. 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. To rebut the presumption of sound condition under section 1111 for conditions not noted at entrance to service, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. See Wagner v. Principi, 370 F.3d 1089, 1094-1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. In this case, the file contains no clinical evidence of a diagnosis of a psychiatric condition made prior to service and the 1985 enlistment examination report indicates that psychiatric evaluation was normal. Post-service evidence similarly fails to establish that a psychiatric disorder clearly and unmistakably existed prior to service. The Board concedes that the opinion provided by a VA psychiatrist in September 2011 indicated that it was "as likely as not" that the Veteran had a psychiatric disorder which preexisted his service, and that the Veteran "may" have had a psychiatric disorder which preexisted his service entrance. However, in his subsequent May 2013 addendum opinion, when directly asked whether there was clear and unmistakable evidence that a psychiatric disorder preexisted service, the psychiatrist explicitly stated that "there is no clear and unmistakable evidence that the veteran had a psychiatric disorder that preexisted service entrance, as there is no evidence in his medical records that he had a psychiatric disorder prior to his military service." Later in his May 2013 opinion, the psychiatrist again stated that "it is unclear to me if the veteran had any preexisting psychiatric disorder." Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). Hence, the Board finds that as there is not clear and unmistakable evidence of a preexisting psychiatric condition to rebut the presumption of sound condition, and accordingly, there is no basis upon which to afford service connection based on aggravation. 38 U.S.C.A. §§ 1111, 1153; 38 C.F.R. § 3.306(a). Where, as here, the government fails to rebut the presumption of soundness under section 1111, the Veteran's claim must be considered one for service incurrence or direct service connection. See Wagner, 370 F.3d at 1094-1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). The Veteran's service treatment records do not reflect that any psychiatric disorder was diagnosed in service and psychiatric evaluation conducted upon periodic examination of September 1991, approximately 6 months prior to the Veteran's discharge from service, was normal. Moreover, there is no indication that the Veteran had a diagnosis of a psychosis manifested to a compensable degree during the first year following his separation from service. Clinical evidence reflects that a psychiatric disorder was not initially diagnosed until more than 10 years after the Veteran's discharge from service. Accordingly, entitlement to service connection for a psychosis on a presumptive basis is also not warranted. See 38 C.F.R. §§ 3.307, 3.309 (2012). Following separation from service in 1992, the Veteran was hospitalized and substance (drug and alcohol) use disorders were diagnosed in 1999 and 2003. The 2003 report mentions depression and substance use linked to the deaths of the Veteran's parents, per his own report. The earliest post-service diagnosis of a psychiatric condition was in 2006, at which time bipolar disorder was diagnosed. However, bipolar disorder initially diagnosed more than a decade after the Veteran's period of service, has not been etiologically linked to the Veteran's period of service or any incident therein, to include the reported deaths of his parents. A requirement for a showing of such a relationship has been repeatedly reaffirmed by the Court of Appeals for the Federal Circuit, which has held that a Veteran seeking disability benefits must establish the existence of a disability and a connection between the veteran's service (or a service connected disability) and the disability claimed. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In fact, the record contains competent medical opinions dated in November 2009 and June 2011, which accounted for and considered the Veteran's lay history and assertions, and which indicated that it was less likely than not that a psychiatric disorder was etiologically related to service. In addition, the psychiatrist who offered the June 2011 opinion reiterated his opinion in May 2013, stating that "I do not believe that it was at least as likely as not that any current psychiatric disorder is etiologically related to or first manifested during the Veteran's period of service." The psychiatrist explained that there was "no evidence in his medical record that his psychiatric disorder first manifested itself during his service" and that "he was not diagnosed with Bipolar disorder until a decade after his discharge." As the aforementioned opinions of 2009, 2011, and 2013 were based on a comprehensive review of the file, as well as consideration of both lay and clinical evidence, and rationale supporting these opinions was offered, the Board considers these medical opinions to be the most probative evidence of record as related to the matter of etiological nexus to service. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In addition, the Veteran has not provided any competent lay or medical evidence rebutting these opinions or otherwise diminishing their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). In contrast, the file contains less probative evidence in the form of the opinions provided upon VA examination of 2008, and the Veteran's lay opinion regarding the etiology of his claimed psychiatric disorder. In 2008, a VA examiner indicated that "it [was] possible that the deaths of [the Veteran's] parents precipitated depressive reactions as part of the bipolar disorder and led to a decline in functioning." The examiner further remarked that "although a PTSD diagnosis [was] not supported, it [was] more likely than not that the deaths of both parents (in 1985 and 1992) aggravated [the Veteran's] bipolar disorder and precipitated depressive reactions which caused a decline in his functioning." The Board observes that an award of service connection may not be based on resort to speculation or remote possibility. See 38 C.F.R. § 3.102 (By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility.); see also Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Bostain v. West, 11 Vet. App. 124, 127 (1998). As such, opinions indicating that something is "possible", such as the opinion made by the VA examiner in 2008, are, for all intents and purposes, inconclusive as to the origin of a disorder and cannot be employed as suggestive of a linkage between a Veteran's claimed disorder and his military service; moreover, that opinion failed to even mention service in relation to the etiology of the Veteran's bipolar disorder. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). In addition, the Veteran himself maintains and has opined that his currently-claimed psychiatric disorder is service related. The Veteran has not demonstrated that he has any expertise to render such an opinion. Moreover, his opinion as to the etiology of the claimed psychiatric disorder is not consistent with the objective evidence of record, which fails to reveal any indication of a psychiatric disorder until more than a decade after service separation or competent and probative medical opinions provided in 2009, 2011, and 2013, which did not establish service-related etiology of any currently manifested psychiatric disorder. See Davidson v. Shinseki, 581 F.3d 1313, (Fed Cir. Sept. 14, 2009); Jandreau v. Nicholson, 492 F.3d 1372 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Accordingly, his assertions regarding etiology of the claimed psychiatric disorder are of no probative value, as they are beyond his competency to make. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (1998); (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Hickson elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Brown, 10 Vet. App. 488, 495- 97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). However, the continuity and chronicity provisions of 38 C.F.R. § 3.303 (b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus.") Nonetheless, a veteran's lay statements may still be sufficient evidence in any claim for service connection. 38 C.F.R. § 3.303(a) ("Each disabling condition shown by a veteran's service records, or for which he seeks a service connection[,] must be considered on the basis of . . . all pertinent medical and lay evidence."); see also 38 U.S.C. § 1154(a) (requiring VA to include in its service connection regulations that due consideration be given to "all pertinent medical and lay evidence"). In this case, the Veteran appears to assert continuity of psychiatric symptomatology in and since service. This assertion, however, is not consistent with the entire evidentiary record. As indicated above, the service treatment records are entirely negative for any psychiatric symptoms or diagnoses. Post-service records first reflect that depression was noted in 2003, in conjunction with treatment for substance abuse. It was not until that time, more than a decade after service, that the Veteran initially mentioned the death of his mother associated with symptoms of depression and substance abuse. The Board notes that this initial report was also coincident with the Veteran's initial service connection claim for a psychiatric disorder filed in July 2003. This length of time from service separation and first documentation of psychiatric symptomatology is not consistent with a finding of chronic disability incurred during active service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without treatment is a proper factor to consider when evaluating continuity of symptomatology). The Board finds the Veteran not to be a credible historian. As discussed at length in the September 2012 Joint Motion for Partial Remand, there record is replete with evidence that the Veteran suffers from memory problems due to his current psychiatric disorder. Treatment notes and examination reports dated from 1999 to 2008 adequately document the Veteran's memory deficits. As such, during the course of this appeal, he has at various times identified the date of his mother's death as 1985, 1986 and even 1988. In addition, he has asserted that the death of his mother resulted in subsequent substance abuse, which is in essence maintained as early psychiatric symptomatology. However, the Veteran has indicated that his drug and alcohol use started as early as 12 years old and began well prior to his mother's death. See the 2009 VA examination report. These inconsistencies and contradictions, whether due to memory deficits resulting from his current psychiatric disorder or other reasons altogether, undermine the credibility of the lay statements and history provided by the Veteran. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). Accordingly, in this case the Board finds the service treatment records, clinical evidence, and opinions of competent medical experts to be the more probative and reliable evidence, than the Veteran's unsupported assertions, made years after his discharge from service. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (personal interest may affect the credibility of the evidence). As to the Veteran's diagnosed substance abuse disorders, and to the extent that the file reflects drug and alcohol use, prior to, during and subsequent to service, compensation cannot be paid if a disability is a result of a person's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. §§ 1110, 1131 (2012). Section 8052 of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Pub. L. No. 101-508, § 8052, 104 Stat. 1388, 1388- 91, prohibits, effective for claims filed, as in the instant case, after October 31, 1990, payment of compensation for a disability that is a result of a Veteran's own alcohol or drug abuse. Moreover, Section 8052 also amended 38 U.S.C.A. § 105(a) to provide that, with respect to claims filed after October 31, 1990, an injury or disease incurred during active service will not be deemed to have been incurred in line of duty if the injury or disease was a result of the person's own willful misconduct, including abuse of alcohol or drugs. See 38 U.S.C.A. § 105 (West 2002); 38 C.F.R. §§ 3.1(m), 3.301(d) (2012). The Board notes that in Allen v. Principi, 237 F.3d. 1368 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit held that a Veteran can receive compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of a service-connected disability. The Court made it clear that in order to grant service connection for alcohol or drug abuse secondary to a service-connected disability, there must be a causal relationship between the service connected disability and the alcohol or drug abuse. The Court stated "clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a Veteran's primary service connected disability and where the alcohol or drug abuse disability is not due to willful wrongdoing" is needed. Allen, 237 F.3d at 1377. In this case, the evidence does not show that a service-connected disorder caused the Veteran's alcohol and drug abuse, nor has any such link been made by virtue of competent medical evidence or opinion. As such, service connection is not warranted for any alcohol or drug abuse disability. For the reasons explained herein, the preponderance of the evidence is against the service connection claim for a psychiatric disorder, to include PTSD, and the appeal as to this claim must therefore be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has considered the doctrine of affording the benefit of any existing doubt with regard to the issue on appeal; however, as the preponderance of the evidence is against the claim, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant the ultimate resolution of the claim on that basis. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a psychiatric disorder is denied. ____________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs