Citation Nr: 1328762 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 04-37 432 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a skin disease, claimed as secondary to service-connected disability. 2. Entitlement to service connection for an acquired psychiatric disorder, to include depression, claimed as secondary to service-connected disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD G. Wasik, Counsel INTRODUCTION The Veteran had active duty service from February 1970 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) located in Winston-Salem, North Carolina. The issues on appeal were previously before the Board in July 2010 and February 2013 when they were remanded for additional evidentiary development. The Veteran had submitted a request to attend a hearing to be conducted by a Veteran's Law Judge but in February 2010, he withdrew the request. FINDINGS OF FACT 1. The competent evidence of record links a current skin disorder to the Veteran's service-connected left lower extremity disabilities via obesity. 2. The most probative evidence of record demonstrates that the Veteran does not have an acquired psychiatric disorder, to include depression, which is etiologically linked to his active duty service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a skin disease on a secondary basis have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include depression, claimed as secondary to service-connected disability, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by letters sent to the Veteran in June 2003, December 2004, March 2006 and March 2013. While the Veteran was not advised of the pertinent information prior to the initial adjudication of the claims, he was provided with sufficient notice subsequent to the initial adjudication and thereafter the claims were readjudicated as evidenced by the May 2013 supplemental statement of the case. The notification defect was cured. 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). The duty to assist was also met in this case. The service treatment records are in the claims file. All pertinent VA and private treatment records have been obtained and associated with the file. VA examinations with respect to the issues on appeal were obtained in May 2013 and in November 2011 with an addendum promulgated in April 2013. 38 C.F.R. § 3.159(c) (4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions obtained in this case are adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. The opinions considers all of the pertinent evidence of record and the statements of the appellant, and the examiners provided complete rationales for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). Competency and credibility The Veteran can attest to factual matters of which he had first-hand knowledge, e.g., experiencing mental disorders and skin problems in service and thereafter. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran as a lay person has not been shown to be capable of making medical conclusions; thus, his statements regarding causation are not competent. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. See Duenas v. Principi, 18 Vet. App. 512, 520 (2004). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997); see also Bostain v. West, 11 Vet. App. 124, 127 (1998). While the Veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court indicated that varicose veins was a condition involving "veins that are unnaturally distended or abnormally swollen and tortuous." Such symptomatology, the Court concluded, was observable and identifiable by lay people. Because varicose veins "may be diagnosed by their unique and readily identifiable features, the presence of varicose veins was not a determination 'medical in nature' and was capable of lay observation." The Court found the veteran's lay testimony regarding varicose vein symptomatology in service represented competent evidence. In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the United States Federal Circuit Court determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as varicose veins, the Veteran is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). See Barr. The question as to the etiology of the Veteran's skin disorder and mental disorder do not involve simple diagnoses or medical assessments. See Jandreau; see also Woehlaert. The Board finds the Veteran is not competent to provide a complex medical opinion regarding the diagnosis or etiology of his claimed skin or mental disorders. See Barr. Service connection criteria Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that, effective October 10, 2006, VA amended 38 C.F.R. § 3.310 with regard to the requirements for establishing secondary service connection on an aggravation basis. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). However, given the basis of the denial, as noted below, any further discussion of the amendment is unnecessary. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran 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). Entitlement to service connection for a skin disease, claimed as secondary to service-connected disability There is evidence of complaints regarding the skin in the service treatment records. In February 1971, the Veteran sought treatment for a macular rash on his neck and back which began the prior night. It spread to his chest and arms the next morning. Physical examination revealed a macular "slapped face" type of rash over the face, neck, back, chest, arms and hands. The impression was drug reaction, probably due to Darvon or Phenobarbital. Later the same month, a clinician wrote that the Veteran was exceedingly nervous when he presented with a rash one week prior. Two days after taking drugs thought to have caused the rash, the rash disappeared. The impression was reactive drug allergy. Significantly, clinical evaluation of the skin and psychiatric status was determined to be normal at the time of the December 1969 entrance examination and at the time of the September 1971 separation examination. Furthermore, the Veteran completed a Report of Medical History in September 1971 wherein he denied having or ever having had skin diseases. This evidence does not support a finding that the Veteran had a chronic skin disorder during active duty. The evidence demonstrates that the Veteran had an acute skin disorder without subsequent manifestations for the remaining seven months of active duty service. The Veteran's own report at discharge weighs against a finding of a chronic skin disorder. There is a long period of time between the time of the Veteran's discharge and the submission of his claim for compensation for the skin disorder. The Veteran submitted his claim in June 2004, more than 30 years after his discharge. Between the time of discharge and June 2004, he submitted claims on at least three separate occasions without claiming problems with the skin. The Board finds this evidence weighs against the Veteran's claim. If the Veteran had had a chronic skin disorder from the time of discharge to the present, it is reasonable to assume that the Veteran would have submitted a claim for that disorder when he submitted the prior claims. This evidence weighs against a finding that there was a chronic skin disorder from discharge to the present. There is post-service medical evidence which documents the presence of various skin disorders. For example, a June 1996 private clinical record reveals the Veteran had a biopsy of a growing black lesion. The impression was rule out melanoma, nevus. Numerous clinical records dated in the 2000's document the presence of venous stasis and also some recent ulcerations. Although there is competent evidence documenting the presence of skin disorders during the pendency of this claim, there is no competent evidence of record which links any current skin disorder to the Veteran's active duty service. No health care professional has opined that a currently existing skin disorder was incurred in or aggravated by the Veteran's active duty service. There is competent evidence of record which demonstrates that the Veteran does not have a current skin disorder which is etiologically linked to his active duty service. A VA skin examination was conducted in September 2010. The examiner reviewed the service treatment records and noted that the Veteran had a rash break out on his neck and chest in February 1971 which was thought to be due to a Darvon allergy. The examiner indicated that the rash resolved after a week or so; the Veteran had not taken anymore Darvon, and so it had not recurred. The examiner opined that the Veteran did not have any current skin problems related to the in-service treatment. The diagnosis was rash due to Darvon allergy which had resolved. Based on the above, the Board finds that service connection is not warranted for a skin disorder on a direct basis. The Veteran has argued that he currently experiences skin disorders which are due to his service-connected disabilities. Service connection is currently in effect for Type II diabetes mellitus, left knee degenerative joint disease, left ankle degenerative joint disease and hypertension. The Board finds that service connection is warranted for a skin disorder on a secondary basis. There is competent evidence of record of the presence of stasis dermatitis. The clinical records associated with the claims file as well as the reports of VA examinations document the presence of stasis dermatitis beginning in the 2000's. Furthermore, some of the clinical records as well as the reports of VA examinations attribute the skin disorder to obesity. A VA diabetes mellitus examination was conducted in September 2010. The Veteran had stasis dermatitis which had its onset ten years prior. He reported he began having chronic leg swelling ten years prior and started to develop rashes of the skin with skin breakdown at times. It was also reported that the Veteran had longstanding bilateral leg edema dating prior to the time of onset of the diabetes mellitus. The pertinent diagnosis was stasis dermatitis of the shins, due to obesity which pre-dated the diabetes mellitus. Another VA skin examination was conducted in November 2011. The diagnosis was dermatitis. It was noted that the Veteran had gradual weight gain over the years since separation from military service which was associated with swelling of the lower extremities and development of pretibial stasis dermatitis. The examiner opined that the Veteran's stasis dermatitis was more likely secondary to obesity and leg swelling with stasis which started in 2002 and has been persistent. The examiner indicated that this preceded a diagnosis of diabetes mellitus and was not likely caused by or aggravated by the diabetes mellitus but rather the dermatitis was more likely related to the Veteran's morbid obesity. The most recent VA examination of the skin was conducted in May 2013. The examiner diagnosed stasis dermatitis. The Veteran reported that approximately twelve years prior, he began to have severe edema in the legs, with oozing and blisters. He used to work in computers with his legs down and this worsened the symptoms. He stopped working in 2004. The examiner opined that the stasis dermatitis was less likely as not linked to active duty service or directly due to the in-service leg injury. He wrote that the stasis dermatitis started 30 years after the service treatment and was bilateral. The in-service injury was to the left leg only. Although the injury could produce stasis dermatitis, the onset of this one is near to the injury not 30 years later and on the side of the injury. The examiner noted that stasis dermatitis generally affects middle aged and elderly patients and can be associated with obesity as it is with the Veteran. In addition to the above, the Board finds that there is competent evidence of record linking the currently existing skin disorder to the Veteran's service-connected left lower extremity disabilities via obesity. In July 2003, a private physician, R.K.K., M.D., wrote that he had been treating the Veteran since October of 2000. He noted the Veteran had injured his left knee and ankle during active duty which subsequently limited the Veteran's ability to ambulate. The limitation has contributed to an inability to maintain a healthy weight over the years and, as a direct result of his injuries and subsequent weight gain, he is hypertensive and also more recently developed diabetes. In December 2003, Dr. R.K.K. wrote that the Veteran had a number of medical problems which included hypertension, chronic depression, diabetes mellitus, obesity, severe chronic venous stasis of the lower extremities, status post left knee and left ankle injuries with chronic pain and disability and glaucoma. He noted the Veteran injured his left knee and ankle during military service and he had had chronic pain and an abnormal gait since that time. Over the years, this resulted in a decrease in his ability to be physically active and has been a "major contributing factor to progressive weight gain and exogenous obesity." The Board finds the private physician's letters provide competent evidence of an etiologic link between the Veteran's current skin disorder and his service-connected left lower extremity disabilities based on the weight gain he experienced. In both letters, the physician linked the skin disorder to a service-connected disability via obesity. The Board notes that, although not precedential, a prior Board decision in this case granted service connection for hypertension and diabetes mellitus based on Dr. R.K.K.'s letter employing the same etiology he advanced for the Veteran's health problems. There is no competent evidence of record which weighs against a finding that the Veteran's left lower extremity disabilities were productive of weight gain. There is no competent evidence of record which weighs against a finding that the weight gain is productive of dermatitis. Based on the above and upon consideration of the benefit of the doubt, the Board finds that service connection is warranted for a skin disorder on a secondary basis. Entitlement to service connection for an acquired psychiatric disorder, to include depression, claimed as secondary to service-connected disability Clinical evaluation of the Veteran's psychiatric status was determined to be normal at the time of the December 1969 entrance examination. In February 1971, a clinician wrote that the Veteran was exceedingly nervous when he presented with a rash one week prior. Two days after taking drugs thought to have caused the rash, the nervousness disappeared. The impression was reactive drug allergy. Clinical evaluation of the Veteran's psychiatric status was determined to be normal at the time of the September 1971 separation examination. The Veteran completed a Report of Medical History in September 1971 wherein he denied having or ever having had depression or excessive worry and nervous trouble of any sort Thereafter there are no complaints of, diagnosis of or treatment for mental disorders until more than 20 years after the Veteran's discharge from active duty. The first medical evidence of complaints of problems with mental disorders is dated in 1993. In July 1993, a clinician wrote that the Veteran was very despondent and depressed over the fact that his business had failed. His was pushed out by his business partner who tried to cheat him and did not pay him his fair share. The document was annotated to indicate the Veteran had work related depression. A clinical record dated in November 1993 indicates the Veteran was prescribed medication for stress/depression. It was reported that the Veteran was under a lot of pressure. In August 1998, the Veteran reported anxiety, stress, and depression at times. He was taking medication. In July 2003, a private physician, Dr. R.K.K., wrote that he had been treating the Veteran since October 2000. He noted the Veteran had injured his left knee and ankle during active duty which subsequently limited the Veteran's ability to ambulate. This contributed to an inability to maintain a healthy weight and, as a direct result of his injuries and subsequent weight gain, he is hypertensive and also more recently developed diabetes. The physician also opined that the Veteran had chronic problems with depression which was directly related to the disability caused by his previous injuries. In November 2003, the Veteran informed the Dr. R.K.K. that he was depressed at times. In December 2003, the private physician, Dr. R.K.K., wrote that the Veteran had a number of medical problems which included hypertension, chronic depression, diabetes mellitus, obesity, severe chronic venous stasis of the lower extremities, status post left knee and left ankle injuries with chronic pain and disability and glaucoma. The physician observed that the Veteran injured his left knee and ankle during military service and he had had chronic pain and an abnormal gait since that time. Over the years, this has resulted in a decrease in his ability to be physically active and has been a major contributing factor to progressive weight gain and exogenous obesity. The additional weight has in turn increased the pain in the left knee and left ankle. In addition, the Veteran had other problems including hypertension, diabetes mellitus and chronic venous stasis of the lower extremities. Chronic pain and disability have also led to symptoms of depression. A medical examination for Social Security purposes was conducted in January 2004. Pertinent complaints were severe chronic venous stasis with superficial ulcers and hypertension. The Veteran informed the physician that he injured his left knee and ankle during military service. Left knee and ankle pain worsened over time. Due to ongoing pain, the Veteran's mobility decreased and he started gaining weight. He informed the physician that, due to the decreased mobility, he gained weight excessively over a short period of time. Later on, he experienced more pain due to the increased weight. He developed hypertension and diabetes mellitus and also lower extremities swelling. Due to chronic venous stasis, he developed dermatitis with superficial ulcers with increased swelling. The Veteran had a history of diabetes mellitus which is also a contributing factor for poor healing of the superficial ulcers. The examiner noted that, due to multiple health issues, the Veteran developed depression. At the time of a September 2010 VA mental disorders examination, the Veteran reported he had difficulty with mental health problems since 1979 and his symptoms were better. He was less impulsive and his temper was improved. He had been taking medication for many years. Medication really controlled his symptoms. He denied being anxious. He used to be sad and reported his low point was 1987. He was not sad at the time of the examination. An examination was conducted. The Axis I diagnosis was history of adjustment disorder with mixed emotional features which was not found at the time of the examination and well controlled on medication. The only psychiatric disorder noted was sleep disturbance. The examiner found the Veteran was not anxious, irritable, withdrawn or sad. He had friends, went to church, had interests, took medication which he tolerated well. The Veteran's psychiatric symptoms were controlled by his medication. At the time of a November 2011 VA psychiatric examination, the examiner diagnosed depressive disorder, not otherwise specified. The examiner found the Veteran was asymptomatic and his depression had been well-controlled with the use of antidepressant medication (Paxil or a Paxil derivative) which he reported he has been taking for many years. The examiner noted that the diagnosis of depressive disorder, not otherwise specified, is used in situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced. The examiner opined that the Veteran only had one mental disorder. Regarding military service, the examiner wrote the Veteran described some problems during his service with his chain of command - specifically a supervisor who the Veteran indicated did not like him and gave him all of the undesirable assignments. The Veteran also indicated he thought this person's dislike for him was probably related to some sort of loss of his service medical records. After his military service, the Veteran worked in a hobby shop for a few months and then was "grandfathered in to work at Baptist." He worked at Baptist Hospital in the lab for seven years and reported that he resigned the position due to his leg problems. He opened a hobby shop with a business partner for about 18 months and started working on computers in his spare time. He said he got married and "worked in computers since that time." The Veteran said he was self-employed, running Carolina Micro consultants, a custom computer system business until about 8 years ago. He said he became "100% disabled" 8 years ago due to his leg-related problems. The Veteran reported he has been on antidepressants for the treatment of depression "ever since I got out of the service" (circa 1971). He informed the examiner his problems with depression started "when I left the service and didn't get my disability." He struggled to articulate any specific symptoms of depression which were present at that time but reiterated that he was treated for depression "ever since I left the service." He indicated his treatment has always been in the form of medication that has been prescribed by his private providers who he identified as Dr. B. in Elkin and Dr. K. He said he has taken Paxil "or a Paxil derivative." The Veteran denied any diagnosis or treatment for other mental health conditions. The Veteran presented as asymptomatic. He reported that with antidepressant medication his mood is fine. He spontaneously reported that his mood has been a lot better since service connection was granted. With regard to etiology, the examiner opined the mental disorder was less likely than not incurred in or caused by any claimed in-service injury, event or illness. The rationale was both the Veteran's current self-report and available treatment records indicate he has a longstanding history of treatment for depression with anti-depressant medication (Paxil). There is no other history of psychiatric diagnosis either reported by the Veteran or evidenced in treatment records. Both the Veteran's self-report and available treatment records indicate he has been psychiatrically stable and essentially asymptomatic for an extended period of time (approximately 18 years per available treatment records). The examiner determined that there is conflicting and inconsistent information about the onset and etiology of the Veteran's problems with depression. The examiner observed that the Veteran alleged he had been treated for depression ever since he got out of military service but also noted that the Veteran struggled to articulate any specific symptoms of depression which were present at that time but reiterated that he was treated for depression ever since he left the service. The examiner further noted that the service treatment records were negative for psychiatric disorders. The examiner observed that private medical records dated from 1980 to 1999 were silent as to any evidence of treatment for depression (or any other mental health related problems) from 1980 until late 1993. The examiner found that a progress note dated in November 1993 is the first indication in the treatment records of any concerns about depression. Prior medical progress notes do not indicate any problems with depression or any other mental health concerns. The note from November 1993 indicates the Veteran was under life stress due to a failed business attempt and financial issues associated with the Veteran's failed business and his business partner; it was noted that the Veteran was demonstrating symptoms of depression. The note indicates Dr. B. started the Veteran on Paxil, an antidepressant medication. Improvement in mood and other depressive symptoms were noted during follow-up visits. Counseling was recommended but the Veteran was not interested. Progress notes indicate the Veteran continued to take Paxil (the anti-depressant medication) and maintained psychiatric stability. Per the Veteran's report (which is consistent with treatment records) his medical care was eventually transferred to Dr. K. Reports from Dr. K. (dated in July 2003 and December 2003) indicate the Veteran was treated for "chronic depression" due to disability, previous injuries, and pain. No information about onset, severity, frequency, duration or specific symptomatology related to the Veteran's depression is noted in these reports from Dr. K. The claims file also contain a social security disability examination report from Dr. S., dated in January 2004, that indicates the Veteran has chronic depression due to multiple health issues. The examiner observed that there was no information included in the opinion report regarding onset, severity, frequency, duration or specific symptomatology related to the Veteran's depression. There is also a copy of a C&P examination conducted with Dr. B. in September 2010. Dr. B. diagnosed a history of adjustment disorder with mixed emotional features. He noted the Veteran was asymptomatic at the time of the exam and that his symptoms were controlled with medication. The examiner opined that the mental disorder was also less likely than not due to the Veteran's service-connected disabilities. The examiner's opinion was based on the fact that the available medical evidence indicates the Veteran's depression most likely had its onset in 1993 after he encountered some life stress related to a failed business attempt. Although the exact etiology of the Veteran's depression is not known, there is no indication the Veteran's depression was caused by any of his service-connected disabilities. The examiner also opined that there was no evidence the Veteran's depression has been aggravated (made worse) by any service-connected disabilities. Treatment records and the Veteran's self-report are consistent: Both indicate the Veteran has been psychiatrically stable with antidepressant medication for an extended period of time (approx. 18 years). The Veteran's problems with depression are clearly documented 10 years prior to 2003 (in Dr. B. 's records from late 1993). By 2003, the Veteran had been stabilized on antidepressant medication for 10 years; both treatment records and the Veteran's self-report indicate he has been psychiatrically stable since 1993. Neither the Veteran nor any available records indicate any diagnosis or treatment for mental health problems other than depression before or after July 2003. An April 2013 addendum to the November 2011 VA mental disorders examination indicates that the examiner reviewed the February 1971 service treatment record which referenced the fact that the Veteran was exceedingly nervous at that time. The examiner reported that the evidence did not change his prior opinion. The examiner found that the February 1971 clinical record was not related to any mental health problems or diagnosis. The progress note was related to a reactive drug allergy the Veteran experienced while taking several prescribed medications for treatment of arthritis. Side effects of those medications experienced by the Veteran included a skin rash and nervousness. These are the know side effects of the various medications the Veteran had been prescribed. The offending medication was discontinued and the side effects dissipated. Initially, the Board notes that the medical evidence of record is devoid of any evidence that the Veteran had a psychotic disorder to a compensable degree within one year of discharge which would allow for a grant of service connection for a psychosis on a presumptive basis. Pertinent symptomatology was not recorded at the time of the Veteran's exit examination and there are no medical records dated within one year of discharge which address the status of the Veteran's mental health. The Veteran has not alleged that he had a psychosis to a compensable degree within one year of discharge. Service connection is not warranted for a mental disorder on a presumptive basis. The Board finds that service connection is not warranted for an acquired psychiatric disorder on a direct or secondary basis as the preponderance of the competent probative evidence of record demonstrates that the disorder was not etiologically linked to the Veteran's active duty service or to a service-connected disability or disabilities. To the extent that the Veteran has opined that he currently experiences a mental disorder due to active duty or due to a service-connected disability, the Board finds such opinion is without probative value. As set out above, the Board finds the Veteran is a lay person and is not competent to provide evidence regarding a complex medical determination. The Board finds that the determination of the etiology of the Veteran's acquired psychiatric disorder is a complex medical determination. With regard to the Veteran's reports of having had continuous mental health symptomatology from active duty to the present, the Board finds that the Veteran is competent to provide evidence of such symptoms. The credibility of the allegations, however, are a separate determination the Board has to make. In the current case, the Board notes that the evidence of record documents the Veteran had a single instance of a report of a mental disorder during active duty but nothing for the remainder of his service or for many years thereafter. In fact, the Veteran denied having any mental disorder symptomatology at the time he completed the Report of Medical History in connection with his separation examination. The private medical records document treatment beginning in the 1980's but do not document complaints of problems with mental disorders until 1993. The Board further notes the Veteran submitted claims for compensation for various disorders in October 1971, November 1971 and June 2003 but did not claim compensation for any mental disorders at those times. The Board finds it reasonable to assume that, if the Veteran had had continuous adverse mental health symptomatology from the time of discharge to the present, he would have submitted a claim for a mental health disorder at the time he was claiming compensation for the other disorders which he perceived were linked to his active duty service. Based on the above discrepancies, the Board finds that reduced probative value should be placed on the Veteran's self-reported medical history which was advanced at a time when there was potential pecuniary gain for the Veteran. The medical evidence which supports the Veteran's claim that he had a mental disorder which is etiologically linked to his active duty service or to a service-connected disability is the opinions from Dr. K and the report of the disability evaluation conducted in connection with the Veteran's Social Security claims. Dr. K. opined that the Veteran experienced depression as a result of injuries to his left lower extremity which resulted in an inability to exercise leading to obesity which caused additional pain which caused depression. The report of the Social Security disability evaluation mirrors this etiology opinion. The Board finds, however, that the probative value of these medical opinions is undercut by Dr. K.'s medical records which document complaints of problems with the Veteran's mental health first beginning in 1993. The medical records, dated more than 20 years after the Veteran's discharge reference problems with mental health which are linked to the Veteran's occupation. The records are completely devoid of any indication that the Veteran experienced any mental health problems due to service or to a service-connected disability. The failure of Dr. K. and the social security examiner to address this fact pattern reduces the probative value of the opinion. A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Additionally, an examination that does not take into account the records of prior medical treatment is neither thorough nor fully informed. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Dr. K.'s records document that the Veteran's mental health symptoms did not begin until many years after the Veteran's discharge and do not indicate that the cause of the depression was active duty or a service-connected disability. The Board finds that the medical opinions included in the report of the November 2011 VA psychiatric examination and addendum is the most probative evidence regarding the etiology of the Veteran's acquired psychiatric disorder. The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The examiner found that the Veteran's acquired psychiatric disorder was not incurred in or aggravated by active duty or due to a service-connected disability. The rationale was that the service treatment records only documented a single instance of mental health problems which the examiner found to be due to medication the Veteran had been prescribed to treat a skin disorder. It was noted that, when the medication was discontinued, the Veteran's psychiatric complaints cease. The examiner then observed that the record was silent for the remainder of the Veteran's active duty service until the 1990's for mental health complaints or treatment and that the Veteran's depression most likely had its onset in 1993 after he encountered some life stresses related to a failed business venture. The Board finds that this medical opinion is entitled to significant probative value as it is based on a review of all the medical evidence of record and reconciles all the medical evidence of record into one cohesive opinion. This examiner also noted and took into account the discrepancy between the Veteran's self-reported medical history and that documented in the medical records associated with the claims file. Based on the above, the Board finds that the most probative evidence of record regarding the etiology of the Veteran's claimed mental disorder indicates that the Veteran's depression is not etiologically linked to active duty or to a service-connected disability. Service connection is not warranted for an acquired psychiatric disorder. For all the foregoing reasons, the Board concludes that the claim for service connection for an acquired psychiatric disorder must be denied. In reaching the conclusion to deny each claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990). ORDER Entitlement to service connection for a skin disorder is granted. Entitlement to service connection for an acquired psychiatric disorder is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs