Citation Nr: 1329319 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 04-38 672 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant (the Veteran) is represented by: Jeffrey J. Bunten, Attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from August 1965 to August 1966. This appeal comes before the Board of Veterans' Appeals (Board) from a November 2010 Order of the United States Court of Appeals for Veterans Claims (Veterans Court). The appeal originates from a January 2004 rating decision of the RO in Indianapolis, Indiana. In a January 2010 decision, the Board denied service connection for PTSD as well as for a personality disorder, but granted service connection for an acquired psychiatric disability other than PTSD. The Veteran appealed that decision to the Veterans Court. In an Order dated in November 2010, pursuant to a Joint Motion for Partial Remand, the Veterans Court vacated that portion of the Board's January 2010 decision which denied service connection for PTSD, and remanded the issue back to the Board for development consistent with the Joint Motion. The Board's January 2010 decision to deny service connection for a personality disorder and to grant service connection for an acquired psychiatric disability other than PTSD were not affected by the Order of the Veterans Court as the parties to the Joint Motion (the Veteran's attorney and a designee of the VA Secretary) stipulated that those matters were not being contested. Accordingly, the issue remaining on appeal is limited to entitlement to service connection for PTSD. In December 2011, the Board remanded this appeal for additional evidentiary development. It has since been returned to the Board for further appellate action. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development needed to fairly adjudicate the appeal has been accomplished. 2. The more persuasive evidence establishes that the Veteran does not have PTSD, and he has not had a valid diagnosis of PTSD during any period pertinent to this appeal. CONCLUSION OF LAW The basic criteria for service connection for PTSD are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran is seeking service connection for PTSD in addition to his already service-connected psychiatric disability (anxiety disorder, depressive disorder, and affective disorder). The Veteran maintains that he has PTSD that is related to combat stressors in Vietnam. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). 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. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that PTSD is not categorized as a psychosis under 38 C.F.R. § 3.384 and is not otherwise included among the chronic diseases specifically listed under 38 C.F.R. § 3.309(a). Therefore, the presumption of service connection for chronic diseases (38 C.F.R. § 3.307(a)) and the provisions regarding chronicity and continuity of symptomatology (38 C.F.R. § 3.303(b)) do not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As previously discussed, this appeal was denied by the Board in January 2010, and that decision was subsequently vacated and remanded due to specific deficiencies in the Board's analysis stipulated by the parties to the Joint Motion. These deficiencies included an inadequate discussion of an April 2003 psychological evaluation conducted on behalf of the Social Security Administration (SSA) and an inadequate discussion of lay evidence of a diagnosis of PTSD, in particular the Veteran's assertion that he has PTSD. Regarding the first deficiency, the Joint Motion refers to an April 2003 psychological evaluation that the Veteran underwent as part of his claim for SSA disability benefits. The examiner, after completing a clinical interview and mental status examination, rendered a diagnosis of PTSD. The parties stipulated that "the Board did not consider and discuss this diagnosis of PTSD. In fact, [the Board] found that other than the August 2003 and 2009 VA examinations, there were 'no other evaluations of record.'" The Joint Motion directs the Board to weigh the credibility and probative value of the April 2003 diagnosis with the other medical evidence of record, and to weigh the credibility and probative value of various VA medical progress notes reflecting a reported history of PTSD and noting that the Veteran was being followed, on account of PTSD. The clinical record in this case is quite large, comprising 5 volumes of evidence and additional electronic medical records. There are multiple psychiatric diagnoses of record, with, in some cases, different diagnoses being cited by the same clinician at different times. The treatment records include primarily VA outpatient records, but also include private treatment records, records pertaining to the disability determination of SSA, as well as several VA examination reports specifically ordered to resolve the question at hand, i.e., whether a diagnosis of PTSD is appropriate during any portion of the period on appeal. While not intended as an exhaustive list, the Board will next list examples of the various references to PTSD and other psychiatric disorders as found in the record, and then proceed to discuss the probative value of each type of reference. A March 1998 VA mental health note from the St. Louis VA Medical Center includes a diagnosis of depression. A May 1999 VA ER assessment includes a preliminary diagnosis of depression and a referral for psychiatric evaluation. A June 1999 mental health note includes diagnoses of PTSD/depressive disorder NOS. However, a few months later, in February 2000, the same clinician diagnosed only depressive disorder NOS, and discontinued listing PTSD. A September 2000 mental health intake note at the Louisville VA Medical Center includes diagnoses of depressive disorder NOS, alcohol dependence in sustained full remission and "? PTSD." Mental health individual therapy notes from October 2000 and November 2000 include essentially the same diagnoses. Subsequent medication management notes in October 2002, January 2003, July 2003, January 2004, and December 2004 also include these same diagnoses. A November 2000 note includes diagnoses of depressive disorder - remission, alcohol and nicotine dependence - remission, and "? PTSD." An August 2002 note includes diagnoses of depressive disorder, alcohol and nicotine dependence and "? PTSD." An April 2003 Primary Care Clinic SOAP note indicates that the Veteran was being treated in the mental health clinic for depression. An April 2003 Primary Care Clinic individual note discusses the Veteran's mental health symptoms and includes the examiner's (readjustment counseling therapist) opinion "I suspect vet very well may have PTSD." The Veteran was rescheduled to "further r/o PTSD." An April 2003 psychotherapy note includes diagnoses of depressive disorder - not responding to the Wellbutrin, history of alcohol and nicotine dependence, and "? PTSD." The Veteran was afforded a VA examination in August 2003. The examiner noted that the Veteran had "some symptoms of PTSD", but he was primarily disabled due to antisocial features and a history of alcohol abuse and dependence. The August 2003 VA examiner provided a diagnosis of depressive disorder, NOS. An October 2003 medication management note includes diagnoses of depression by history - stable, "PTSD traits," and alcohol dependence by history. January 2004, April 2004, and December 2004 notes include diagnoses of depressive disorder, history of alcohol and nicotine dependence, and "? PTSD." A March 2005 mental health clinic psychotherapy note includes diagnoses of depressive disorder - remission, history of alcohol and nicotine dependence in remission, and "PTSD sx." An August 2005 mental health clinic medication management note includes diagnoses of depressive disorder - remission, history of alcohol and nicotine dependence in remission, and "PTSD sx - no complaints this visit." A May 2006 psychiatry note indicates that the Veteran was seen for a PTSD assessment on May 25, and that progress notes should be reviewed. February 2006, April 2007, March 2008, and October 2010 primary care physician notes each list a history of PTSD/depression and each includes an impression of depressive disorder/PTSD. A February 2006 primary care physician note lists issues the Veteran is being "followed" for, including PTSD. An April 2008 psychiatry note indicates that the Veteran is being treated for depression and PTSD. An August 2009 VA examiner concluded that the Veteran did not have a current diagnosis of PTSD. The examiner recognized that the Veteran "very likely" had met the full criteria for PTSD in the years following his service, but that his symptoms had attenuated, and thus, such symptoms no longer rose to a level that warrants the assignment of a DSM-IV PTSD diagnosis. February 2010 and September 2010 notes includes diagnoses of depressive disorder NOS and dysthymic disorder based on mental status evaluations. In March 2011, the Veteran was referred for neuropsychological evaluation for suspicion of cognitive impairment related to mood - rule out dementia. A March 2011 geriatric psychiatry note by the same clinician includes diagnoses of alcohol abuse/dependence, "r/o ptsd," history of depression, and cognitive disorder NOS. A comprehensive neuropsychological testing consultation was conducted on March 31, 2011. The Veteran's medical, mental health, and social and occupational history were detailed, including the Veteran's service history. A mental status examination was conducted, including tests of cognitive and psychological functioning. The diagnoses rendered included cognitive disorder NOS, and depressive disorder NOS. An April 2011 evaluation reveals that the Veteran endorsed a history of depression and current depressive symptoms that are sub-threshold for a diagnosis of major depressive disorder. He also endorsed sub-threshold PTSD symptoms that appeared largely unchanged since the last VA examination completed in 2009 and thus he was also diagnosed with Anxiety Disorder NOS. The Veteran endorsed daily worry about a variety of topics and thus was also diagnosed with generalized anxiety disorder. He reported a history of alcohol abuse and current abstinence. An April 2011 report by the same clinician who conducted the March 2011 geriatric psychiatry evaluation reveals in one location that the Veteran was being treated for Axis I depression NOS, and in another location that he had depression/PTSD; however, the PTSD diagnosis was discontinued in an August 2011 report from the same clinician, at which time the diagnoses were anxiety disorder NOS/depression. The same clinician again examined the Veteran on several subsequent visits. In October 2011, she diagnosed depression NOS. In May 2012, she diagnosed rule out dementia, and mood disorder NOS. The Veteran reported continued anxiety with concerns about memory changes - getting lost - suggestive of progressive memory loss. In August 2012, she diagnosed depression and "subthreshold PTSD." In March 2013, she diagnosed depression NOS. The report of VA examination in March 2013, which resulted from the Joint Motion and Board remand, included the diagnosis of anxiety disorder NOS. The examiner specifically found that a diagnosis of PTSD that conforms to DSM-IV criteria was not supported, and that the Veteran did not have more than one mental disorder. The examiner found that the Veteran's report of stressors does fulfill criterion A, in that he experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others, and the Veteran's response involved intense fear, helplessness, or horror. The examiner also found that the Veteran meets criterion B, in that he does report symptoms of re-experiencing the events, including images, thoughts or perceptions (reports that his memories are triggered by news stories or other reminders of Vietnam; specifically endorses intrusive thoughts of a deceased soldier on a pike and other deceased soldiers). The examiner found that there are recurrent distressing dreams of the event, as well as physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, but that the traumatic event is not persistently reexperienced. However, the examiner found that the reported symptoms of arousal and avoidance are not sufficient in breadth or severity to warrant a diagnosis of PTSD. He found that there is no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. The examiner concluded that a diagnosis of PTSD was not supported, and the diagnosis of anxiety disorder, NOS was continued and found to be more likely than not related to his military service/fear of hostile military/terrorist activity. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). After a review of all of the evidence, the Board finds that the more persuasive evidence demonstrates that the Veteran does not have PTSD, and that a diagnosis of PTSD is not clinically supported at any time pertinent to the current claim and appeal. An important basis for weighing various references to PTSD is the purpose for which they are recorded. This can generally be surmised from the context of report. See Lee v. Brown, 10 Vet. App. 336 (1997) (a medical opinion should be viewed in its full context, and not characterized solely by the medical professional's choice of words). Simple references in the medical record that the Veteran is being followed for PTSD or noting a diagnostic history of PTSD are not presented as comprehensive diagnoses, but are presented typically in summary or list format to give treatment providers an overview of the Veteran's various disorders, and in some cases, the medications prescribed for each. Such non-diagnostic references may be based on a discussion with the Veteran. In this case, the Veteran has often informed treatment providers that he has PTSD or is being treated for PTSD. Such references may also be based on a review by the clinician of the Veteran's treatment records. However, in a voluminous record such as this one, the variances in diagnoses, preliminary diagnoses, and questioned diagnoses, undoubtedly increases the likelihood of a disconnect between these informational references and the concurrent concensus of his psychiatric treatment providers as to his actual diagnosis. For example, a January 2003 primary care clinic SOAP note lists a diagnosis of "depression, followed in MHC." February 2004 and September 2004 primary clinic SOAP notes list a diagnosis of "depression, PTSD-MHC f/u." A primary care clinic SOAP note in September 2005 returns to the first diagnosis of "depression-mhc f/u." Significantly, none of these particular reports include a psychiatric evaluation; they simply record various musculoskeletal and digestive complaints. The examination portion of each report appears limited to basic vital signs. Thus, when these references to PTSD are read in the context of the entirety of each report, it is clear that the Veteran's mental health was not being assessed during these visits, and therefore, the listing of a diagnosis of depression or PTSD is interpreted as non-diagnostic. Similarly, a December 2006 optometry note includes a problem list section in which depressive disorder is listed. The Board finds that it is virtually unarguable that the Veteran's mental health was not assessed by his optometrist. Such non-diagnostic references carry no implication that the observer either personally endorses the diagnosis or has conducted sufficient evaluation of the Veteran to offer an opinion as to the diagnostic validity of the reference. There is a fundamental difference between such informational references recorded in medical treatment records and a diagnosis that is presented as such, that is based on a concurrent examination of the Veteran conducted for the specific purpose of reaching a diagnosis and determining an appropriate course of treatment. A diagnosis based on such an examination carries the assurance that the examiner personally endorses the diagnosis and has conducted whatever testing is necessary to ensure that his/her endorsement actually means something. To the Board, the difference between these informational and diagnostic references translates directly to probative weight. In fact, the vast majority of references to PTSD in the record consist of rule-out diagnoses and diagnoses with a question mark. Such references only indicate that the disorder is possible, or is suspected. They essentially amount to speculation on the part of the clinician. Similarly, the statement included in the April 2003 Primary Care Clinic individual note that "I suspect vet very well may have PTSD," is inconclusive as demonstrated by the use of the word "may." The Veterans' Court has repeatedly and consistently rejected medical opinions raising only a possibility of diagnosis or medical nexus as being insufficient to establish such diagnosis or nexus. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2000); Beausoleil v. Brown, 8 Vet. App. 459 (1996). Medical evidence which merely indicates that the particular disorder "may or may not" exist is too speculative in nature to establish the presence of said disorder. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Some references to PTSD are shortly followed by a different diagnosis by the same clinician. This can logically be interpreted as a change of mind. In this case, a June 1999 mental health note includes diagnoses of PTSD/depressive disorder NOS. However, a few months later, in February 2000, the same clinician diagnosed only depressive disorder NOS, and did not list PTSD. In addition, an April 2011 report reveals an assessment of depression/PTSD; however, the PTSD diagnosis was discontinued in an August 2011 report from the same clinician, at which time, and in several later assessments, the diagnoses were anxiety disorder NOS/depression. Thus, in each case, what was initially thought to be PTSD was upon later evaluation determined to be a different diagnosis. This change of mind also translates to probative weight. References to PTSD traits, PTSD symptoms (PTSD sx), or sub- threshold PTSD by clinicians do not constitute a diagnosis of PTSD. The criteria for a diagnosis of PTSD are established in the DSM-IV. VA regulations incorporate the provisions of the DSM-IV. 38 C.F.R. §§ 4.125, 4.130. A reference by a clinician that certain traits or symptoms of PTSD are demonstrated does not establish a diagnosis; indeed, the inclusion of such caveats or qualifiers directly implies that a full diagnosis is not believed to be supported. In other words, there is no need to refer to PTSD traits if you believe the patient actually has PTSD. In addition, references to a history of PTSD cannot necessarily be interpreted as a diagnosis. The question that must be determined is whether there is a diagnosis of PTSD at any time since the claim was filed. McClain v. Nicholson, 21 Vet. App. 319 (2007) (the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative). In this case, April 2007 and October 2010 primary care physician notes list a history of PTSD/depression, as does a February 2006 primary care physician note cited in the Joint Motion. The October 2010 note includes an impression of depressive disorder/PTSD f/u psy. A March 2008 primary care physician note also cited in the Joint Motion lists an impression of depressive disorder NEC/PTSD. A February 2006 primary care physician note lists issues the Veteran is being "followed" for, including PTSD, and includes PTSD among the various diagnoses. However, in each case, as would be expected with a primary care physician encounter, only a physical examination was conducted, there was no mental examination. Moreover, the references to a history of PTSD are not interpreted as a finding that PTSD is a current disability, or that it has been present at any specific time pertinent to the appeal. The finding of a history of PTSD is perfectly consistent with the opinion of the August 2009 VA examiner, who concluded that the Veteran "very likely" had met the full criteria for PTSD in the years following his service, but that his symptoms had attenuated, and thus, such symptoms no longer rose to a level that warrants the assignment of a DSM-IV PTSD diagnosis. There is also the problem that, listing a diagnosis in this format (PTSD/depression) indicates that the individual recording this information makes no distinction between the two diagnoses, or treats them as one. For many purposes, it is understandable that the distinction is not relevant. VA has chosen to create one general rating formula for mental disorders. See 38 C.F.R. § 4.130. Depression is treated alternatively as a symptom and as a diagnosis. However, for the purpose of this decision, the distinction between PTSD and depression is crucial. Thus, notwithstanding the Board's finding that a history of PTSD does not necessarily indicate PTSD during any period pertinent to the appeal, the Board also finds that a diagnosis of PTSD/depression, like a diagnosis of depressive disorder NEC/PTSD, as cited in the Joint Motion (March 2008 progress note stating "Impression/Plan: 1) Depressive Disorder NEC/PTSD), suffers many of the same deficiencies as a questioned diagnosis. It is inconclusive as to which diagnosis is appropriate and indicates an uncertainty or indifference on the part of the writer as to which diagnosis is actually supported. This does not reduce the probative weight of such a diagnosis to zero, as both diagnoses might be intended; however, where the intent is not expressed and discussed by the clinician, it reduces the probative weight in comparison to a diagnosis rendered with the intent of diagnostic precision, and where the reasons for ruling in or out specific diagnoses are provided. The parties to the Joint Motion cited a May 2006 health summary noting "Diagnosis: 309.81-Posttraumatic Stress Disorder." The Board notes that this is included in an "Outpatient Encounter" list, which is a recordation of treatment provided for a given time period. The full note describes a psychiatric diagnostic interview conducted on May 25, 2006. The actual May 25, 2006 interview reads as follows (minimally edited, primarily for punctuation, capitalization and spelling): Seen for evaluation: patient in Vietnam for six months; got into fight with NCO and discharged as undesirable; also says he was told he had a mood disorder; this was subsequently upgraded. Got all F's in school, and took odd jobs rather than continue; says he has his GED. Came back here from other VA hospital, taking trazodone. Says he has nightmares; not s/c for PTSD. Mental: nothing grossly unusual, no looseness, affect appropriate, intellectual faculties intact; impression: deferred, recommend: refilled his trazodone. We talked about side-effects. This patient would probably be best managed in MPD. When weighing what appears to be an administrative notation recording a patient encounter against the actual record of that encounter, the Board finds the clinician's report to be a more accurate reflection of his clinical findings. The clinician who met with the Veteran on May 25, 2006 did not render a diagnosis of PTSD and only mentioned PTSD in the context of reporting that service connection was not in effect for it. The Board finds that, in the context of the clinical report prepared, the May 2006 reference does not constitute or otherwise represent an actual diagnosis of PTSD. The Board acknowledges that the record does contain diagnoses of PTSD. These include a April 2003 SSA psychological evaluation and a May 2003 SSA mental residual functional assessment, both of which include diagnoses of PTSD and major depressive disorder. In addition, a March 2011 private assessment includes diagnoses of PTSD/major depressive disorder. Regarding the SSA assessments, the May 2003 mental residual functional assessment is apparently for the purpose of determining the Veteran's ability to engage in employment. The report reads: claimant with diagnoses of record MDD & PTSD. The report then goes on to discuss the Veteran's living arrangements and functional capacity. In the notes portion, the examiner wrote that the Veteran "reports PTSD sx at [service separation] but prev. findings give different picture of military, kicked out [secondary] to beating sarg." The examiner specifically noted that he was unable to obtain VA treatment notes and it was not clear whether the Veteran was being treated or not. By the examiner's own description, the diagnoses were gleaned from the record. The examiner included no analysis or discussion of whether and why the diagnoses were appropriate, and he seemed to question the Veteran's account of pertinent details of his disability. In comparison to the March 2013 report, which provides the clinician's reasoning for including one diagnosis and excluding others, the Board finds that the probative value of this report, in terms of whether a diagnosis of PTSD is actually appropriate, is minimal. Regarding the April 2003 psychological evaluation, the Board notes that, although a diagnosis of PTSD is listed at the end of the report, it is mentioned nowhere else in the report. The examiner referred exclusively to "depression" in the body of the report, i.e., "[h]e stated he has suffered depression since 1980's," and "[h]e was doing better until his car accident and his depression has been worse since then." The Veteran's service is noted in the report, as well as the Veteran's account that he "witnessed a lot of killings." However, this is immediately followed by "[h]e suffers from depression." The Board presumes from its inclusion in the diagnosis section that the examiner believed the diagnosis of PTSD to be appropriate; however, it is entirely unclear from the report why he believed this to be true, and why he believed that all of the DSM-IV diagnostic criteria were met. This is a significant point because the record contains several opinions finding that not all of the diagnostic criteria for PTSD are met. While the Board is not competent to provide a diagnosis, it is the Board's responsibility to compare and weigh the opinion evidence in light of reasoning expressed by a competent clinician. As noted above, the weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal, 5 Vet. App. at 461; Sklar, 5 Vet. App. 140. In the case of the April 2003 SSA evaluation, the reason for the diagnosis is not given, and this diminishes its probative weight as compared to the March 2013 VA opinion. The record also contains a March 2011 private report, which includes a diagnosis of "PTSD/MDD." The report suffers from the same deficiency as the April 2003 report. The report is quite minimal, consisting almost entirely of a few hand- written notes. There is no discussion whatsoever as to the propriety of the diagnosis of PTSD and no discussion of the factors underlying the diagnosis, such as which of the diagnostic criteria were satisfied. In comparison to the March 2013 VA opinion, the March 2011 private report carries diminished probative weight, as the basis for the opinion is not stated. In sum, while the Board acknowledges that the record does contain diagnoses of PTSD, the bases for these diagnosis are not explained in any detail; and, in particular, the diagnostic criteria found to be lacking by the March 2013 VA examiner are not discussed. This decreases the probative weight of such diagnoses in comparison to the March 2013 diagnosis. The parties to the Joint Motion also stipulated that, on remand the Board must provide an adequate statement of reasons or bases for its analyses of any lay evidence in support of claim. This refers to the previous finding of the Board that it is well-established that lay persons without medical training, such as the Veteran, are not competent to comment on medical matters such as diagnosis. The parties cited Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (rejecting the view that competent medical evidence is required when the determinative issue involves medical etiology or a medical diagnosis) and Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007) (providing situations in which lay evidence may be used to diagnose a condition). Citing also Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) ("[l]ay testimony is competent ... to establish the presence of observable symptomatology and 'may provide sufficient support for a claim of service connection'" (quoting Layno v. Brown, 6 Vet. App. 465, 469 (1994))). The Board notes that, in the March 2013 VA examination, the Veteran clearly presented his belief that he meets criteria for PTSD and that he has been misdiagnosed by VA providers. He has also reported to other treatment providers that he has PTSD, and his appeal of the current issue even though service connection has already been granted for a psychiatric disability demonstrates that he believes a diagnosis of PTSD is appropriate. In reviewing the Veteran's written assertions supporting the current claim and appeal, the Board notes that his assertions are focused primarily on the events of service and his description of stressors. Such factors are essentially not outcome determinative in this case. Without persuasive evidence that the Veteran actually has PTSD, the matter of a verified stressor is not reached. Regarding the Veteran's assertion that he has been misdiagnosed by VA and that he actually has PTSD, it is important to consider that, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), distinguishing between and among various psychiatric diagnoses falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). There is no question that the Veteran has a psychiatric disability that is related to service, as service connection has already been granted for an acquired psychiatric disability to include anxiety disorder, depressive disorder and affective disorder. The Board finds that distinguishing between and among psychiatric or mental diagnoses is not a matter that is capable of lay observation, but requires some professional training and expertise. Therefore, to the extent that the Veteran asserts that he has PTSD in addition to the various other psychiatric diagnoses for which he is already service- connected, the Board finds that this assertion is not competent evidence. In summation of the Board's findings, as the more persuasive evidence establishes that the Veteran does not have PTSD, service connection under the provisions of 38 C.F.R. §§ 3.304(f) is not warranted. In reaching this conclusion, 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 applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Veterans Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the Veteran submitted a claim for service connection for PTSD in February 2003. He was sent a letter in March 2003 which advised him of the information and evidence necessary to substantiate the claim. Subsequent letters dated in November 2004 and August 2006 provided similar information. The August 2006 letter, as well as a VA examination notice letter dated in July 2009, advised him as to how disability ratings and effective dates were assigned in the event of a successful claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A February 2013 stressor solicitation letter also provided notice of the type of evidence necessary to substantiate the claim. Although most of the letters were not sent prior to initial adjudication of the Veteran's claim, this was not prejudicial to him, since the claim was readjudicated following the post-decisional notice and additional supplemental statements of the case were provided to the Veteran in September 2009 and April 2013. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In short, VA has complied with its duty to notify the Veteran in this case. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, records pertaining to a disability determination by SSA, and the Veteran's written assertions. The RO and the VA Appeals Management Center (AMC) made several attempts to verify the Veteran's multiple claimed stressors. In this regard, in December 2008, the AMC submitted a request for morning reports of the Veteran's unit to the Personnel Information Exchange System (PIES); the response from PIES indicated that such records were not stored there. In March 2009, the AMC requested the same information from National Archives and Records Administration (NARA), whose April 2009 response indicated that such records were stored at the U.S. Army Joint Services Records Research Center (JSRRC). In June 2009, the AMC submitted the Veteran's claimed stressors to the JSRRC for verification. In a June 2009 response, the JSRRC stated that they had determined that the information concerning the stressors supplied by the Veteran was insufficient to allow for meaningful research of records. In response to the Board's December 2011 remand, the Veteran was afforded an additional opportunity to provide stressor information that might be verified; however, he did not respond to the RO's February 2013 request. The Board finds that there is no reasonable possibility that additional attempts would be productive. The Veterans Court has held that VA's duty to assist in developing the facts and evidence pertinent to a claim is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is the responsibility of veterans to cooperate with VA. See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992). Moreover, in light of the basis for the Board's decision, i.e., that the Veteran does not have PTSD, any error in VA's attempts to assist in obtaining a verified stressor are not prejudicial. In addition, the Veteran was afforded VA examinations to address the nature and etiology of the Veteran's psychiatric disability in August 2003, August 2009, and March 2013. These examinations are adequate because each was performed by a medical professional who reviewed the Veteran's complete claims file, to include his service medical records, past medical history, recorded his current complaints, and conducted an appropriate psychiatric examination and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Veteran has not 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 Veteran 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). As noted above, this appeal involves a remand by the Board for additional evidentiary development. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The first remand instruction was to request that the Veteran provide any additional information required in order for JSRRC to research his reported stressors. If the Veteran were to provide the requested information, the RO or the AMC was to request that the JSRRC attempt to corroborate the alleged stressors. As discussed above, this was accomplished, and no response to February 2013 solicitation letter was received from the Veteran. The second remand instruction was to schedule the Veteran for a VA psychiatric examination including claims file review. This was accomplished in March 2013. As instructed, the examiner made a determination as to whether the Veteran has PTSD, finding that he did not. The negative finding obviated the need to address the etiology of PTSD. The examiner provided a rationale for the opinion. As there has been substantial compliance with the Board's remand instructions, an additional remand for corrective action is not necessary. ORDER Service connection for PTSD is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs