Citation Nr: 1330633 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 07-37 342 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of cold injuries. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARINGS ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran had active duty service from September 1964 to August 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied the benefits sought on appeal. A hearing was held in October 2007 before a local Decision Review Officer (DRO). Thereafter, the Veteran and his spouse testified during an April 2010 hearing at the RO before the undersigned Acting Veterans Law Judge (Travel Board hearing). Transcripts of these proceedings have been associated with the record on appeal. The Board has twice previously remanded this case to the RO (via the Appeals Management Center (AMC)). The Board previously remanded this case for VA examinations to address the etiology of any current psychiatric disorder and cold weather injury residuals, for issuance of a notice letter addressing the criteria for substantiating PTSD claims based on personal assault, so that any outstanding VA treatment records could be obtained, and for further development with corroborating the Veteran's numerous stressors related to his PTSD diagnosis. Most recently in September 2012, the Board remanded the case for issuance of a Supplemental Statement of the Case (SSOC) addressing recently obtained VA outpatient treatment records associated with the Veteran's electronic "Virtual VA" claims folder. The matter has since been returned to the Board for an appellate disposition. Upon review of the file the directives of the Board's remands have been substantially complied with. FINDINGS OF FACT 1. The preponderance of the competent evidence weighs against the finding that the Veteran's present condition warrants a diagnosis of PTSD; and no other psychiatric disorder of record has been attributed to the Veteran's military service. 2. The preponderance of the evidence weighs against finding that the Veteran currently has a clinical condition of the upper or lower extremities as a result in-service cold injuries. CONCLUSIONS OF LAW 1. The criteria are not met to establish service connection for an acquired psychiatric disability, claimed as PTSD. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f) (2013). 2. The criteria are not met to establish service connection for residuals of cold injuries. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist the Claimant The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2013), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326 (2013). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 38 CFR 3.159(b)(1) (2013). The United States Court of Appeals for Veterans Claims (Court) has further held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), 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, including notice to the claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Through VCAA notice correspondence dated from December 2006, the RO notified the Veteran as to each element of satisfactory notice set forth under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). The VCAA notice further advised the Veteran of the responsibilities for providing supporting evidence, and that VA and the Veteran had joint obligations to obtain pertinent evidence and information, stating that VA would undertake reasonable measures to assist in obtaining additional VA medical records, private treatment records and other Federal records. See Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). The VCAA notice further explained how VA establishes disability rating and effective date elements of a claim for service connection. In September 2010, the RO also sent the Veteran a notice letter addressing the evidence that can be submitted for substantiating a service connection claim for PTSD based on personal assault. The relevant notice information must have been timely sent. The Court in Pelegrini II prescribed as the definition of timely notice the sequence of events whereby VCAA notice is provided in advance of the initial adjudication of the claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The VCAA correspondence in this case preceded issuance of the rating decision on appeal, and thus met the standard for timely notice. The RO/AMC has taken appropriate action to comply with the duty to assist the Veteran with his claims through obtaining service treatment records (STRs), personnel records, and records of VA outpatient treatment. There were no outstanding private treatment records to obtain. The Veteran has also undergone VA Compensation and Pension examinations with regard to both claims on appeal. The Board in its September 2010 remand directed the RO to provide a VA examination addressing the Veteran's psychiatric disorder to address whether it was at least as likely as not that the Veteran had PTSD related to service, or whether any of his other psychiatric disorders were related to his military service. In providing the assessment in April 2011, the VA examiner did not use the terminology, "at least as likely as not". However, the Board still finds that the examination findings substantially comply with the Board's remand, as there is sufficient detail and rationale provided for why the examiner determined that the Veteran did not have PTSD and why his other psychiatric disorders were related to non-military factors. The RO/AMC has properly implemented the Board's prior remand directives, to particularly include undertaking all reasonable measures to assist the Veteran with the independent corroboration of his alleged stressors in support of the claim for service connection for PTSD. Meanwhile, in furtherance of his claims, the Veteran has provided several personal statements, and newspaper articles contemporaneous with his service. There is no indication of any further relevant evidence or information that has not already been obtained. The Veteran was afforded a hearing before a Decision Review Officer (DRO) in October 2007, and hearing before an Acting Veterans Law Judge (AVLJ) in April 2010, in which he and his wife presented oral argument. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the Veteran, who was represented by a Veterans Service Organization, acknowledged that the service connection claims for PTSD and residuals of cold weather injuries were on appeal and provided testimony regarding why he was contending that these disabilities were related to military service. The AVLJ and DRO did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the claims. The DRO asked specific questions, however, directed at identifying the criteria for service connection for PTSD and residuals of cold weather injuries. The AVLJ also sought to ensure that all outstanding treatment records were in the file. This was not necessary, however, because the Veteran volunteered his treatment history and present symptoms. Accordingly, the Veteran is not shown to be prejudiced on this basis. Also, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board or DRO hearings. In sum, the record reflects that the facts pertinent to the claims have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claims on the merits. Governing Law and Regulations Under VA law, service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303(a) (2013). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). The elements of a valid claim for direct service connection are as follows: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Regarding direct service connection, where a chronic disease is shown during service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required where the condition noted during service is not shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. Under the latter circumstances, a showing of continuity of symptomatology at the time of service discharge and continuing thereafter is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has since clarified in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) that the availability of continuity of symptomatology as a principle to substantiate service connection is limited to where involving those specific diseases denoted as "chronic" (and for which presumptive service connection is otherwise available) under 38 C.F.R. § 3.309(a). The determination as to whether the requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Generally, lay statement evidence may have direct relevance to establishing underlying components of a claim for service connection. In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit commented that competence to establish a diagnosis of a condition can exist when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Lay testimony where found credible is also competent to establish the presence of continuity of symptomatology for a claimed disability during and since separation from military service (again, subject to the limitation that a "chronic" disease is involved as defined under 38 C.F.R. § 3.309(a)). See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Federal Circuit further held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010), that it is error to suggest that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. However, as also observed by the Federal Circuit, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). In addition, the specific regulatory criteria for establishing service connection for PTSD are: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which provides that all psychiatric diagnoses must conform to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy," as established by recognized military combat citations or other official records. See, e.g., Hayes v. Brown, 5 Vet. App. 60, 66 (1993); Cohen v. Brown, 10 Vet. App. 128 (1997). If VA determines the veteran engaged in combat with the enemy and his alleged stressor is combat-related, then his lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required provided that such testimony is found to be "satisfactory," i.e., credible, and "consistent with the circumstances, conditions, or hardships of service." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d); Dizoglio v. Brown, 9 Vet. App. 163, 164 (1996); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Under the former version of applicable law, if the veteran's stressor was unrelated to participation in combat, then his lay testimony, in and of itself, was categorically insufficient to establish the occurrence of the alleged stressor. Instead, the record must have contained credible supporting information from an independent source that corroborated his testimony or statements, such as service records, or even competent lay testimony from a third-party. See Cohen, 10 Vet. App. at 146-47. See also Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996). Apart from the above provisions, however, effective July 13, 2010 VA revised the regulation governing adjudication of claims for service connection for PTSD. See 75 Fed. Reg. 39,843 (later codified at 38 C.F.R. § 3.304(f)). The updated regulation essentially removes the requirement that there be objective corroboration of a claimed in-service stressor under certain circumstances. Under the revised standard, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. Background and Analysis Service Connection for an Acquired Psychiatric Disorder, Including PTSD The Veteran has testified as to multiple stressors. The Veteran testified regarding one stressor involving a fight that resulted in five stitches on his forehead. The Veteran noted that a sergeant kicked him, hit him, and knocked him down. The Veteran claimed he did not report the sergeant because he did not want him sent to jail for a simple fight. Service treatment records (STRs) indicate that the Veteran's July 1964 service induction examination noted mild anxiety. A September 1965 clinical record indicates that the Veteran had recently fallen at headquarters and sustained a 3-cm fairly jagged laceration of the forehead. He talked about "getting even" with an SP-5. He was drunk and rather reluctant to suturing. On separation, no pertinent findings were noted. The Veteran's service treatment records support his statement regarding getting into a fight and the Board finds this stressor to be credible. Otherwise, there was no indication of any specific findings that would immediately be correlated with any of the Veteran's claimed in-service stressors (discussed in more detail below). Thereafter, in January 2003 the Veteran underwent a brief VA hospitalization for alcohol abuse. A February 2005 VA PTSD screen was positive and the Veteran reported that he had had depression "since birth. A September 2006 VA PTSD screen also was positive. However, an April 2007 PTSD screen was negative. The Veteran also has other mental health diagnoses including agoraphobia with panic and dysthymic disorder. In March 2005, he presented at a VA outpatient clinic recalling incidents while assigned to a unit in Germany in the 1960s with poor morale and other problems. He related that soldiers were murdered and physically attacked, the chain of command had broken down, and drugs and guns were used frequently. He reported having to fight, stay on his guard, and observing others being beaten and hospitalized. The evaluating VA social worker observed that the Veteran's description of what occurred in Germany seemed credible. In April 2005, the Veteran presented as a self-referral, stating that his anxiety, stress and related symptoms came from a tour in Germany and maintaining that these were the cause of PTSD. In October 2005, the Veteran was seen for reevaluation of agoraphobia with panic and dysthymic disorder, following having been prescribed psychotropic medication. The assessment was generalized anxiety disorder (GAD), agoraphobia with panic disorder; dysthymic disorder; and alcohol abuse. On a September 2006 VA mental health consult, the Veteran described stress from fear of being assaulted, having to fight with other soldiers and being around people he could not trust. He stated that the daily stress had affected him ever since. The Veteran and his spouse spoke of their troubled marriage, failures, the Veteran's nightmares and his violent anger outbursts. On contemporaneous records, it was noted that the Veteran endorsed many of the symptoms of PTSD. Subsequent VA records include an August 2007 notation that the Veteran was not accepted for admission into a VA PTSD treatment program, as he did not have an established diagnosis of the underlying condition. Then a November 2008 mental health consult with a VA psychiatrist did result in a PTSD diagnosis, following a clinical interview and evaluation of service-related reported history. A March 2009 VA mental health record also notes an Axis I diagnosis of PTSD; alcohol dependence, in remission, per Veteran's report. A December 2010 individual therapy consult indicated a diagnosis of alcohol dependence, depressive disorder not otherwise specified (NOS), and PTSD by history. A February 2011 clinical assessment stated that a PTSD diagnosis "was suggested." Through his ongoing VA treatment records, as well as statements in connection with this claim, the Veteran has set forth several claimed in-service stressors. He has indicated that while stationed in Schweinfurt, Germany his occupation involved being a forward observer for mortars, and while in this company he experienced most of his trauma. He reports an incident where he and some German friends were attacked and the ensuing fight stopped when the German police and Military Police (MPs) arrived; but a few days later he was again accosted by these individuals and for moment had a knife put to his throat before being let go. The Veteran further reports witnessing his friend J.S. being attacked, and being unable to render assistance, which ultimately required his friend to require serious medical attention for injuries. Then a friend L. was assaulted by another restaurant patron with a knife while trying to protect a waitress from harassment, to which L. was able to defend himself by brandishing a pistol. Next, the Veteran describes on at least two occasions directly witnessing members of his unit attempt suicide, and on one occasion calling an ambulance for a person who had deliberately swallowed an overdose of medication and who later survived. He has further described an incident in which a soldier was killed in an accident while driving a tank, and he later observed the efforts to evaluate and then return the accident scene back to its previous state. The Veteran has described numerous other instances of being involved in physical conflagrations, witnessing them on the streets of Germany, and particularly witnessing and having to participate in violent episodes in the base mess hall and sleeping quarters. He states there was at times what he describes as considerable racially motivated violence. The Veteran has also submitted numerous newspaper clippings from the 1960s which refer to problems involving race relations in the military specifically in Germany. The Veteran's wife testified that she knew him before he entered service and that he came back a completely different person. For instance, he did not want to be around people. The Veteran testified that he had nightmares of the events in service. Following RO informational inquiries regarding some of the Veteran's alleged stressors, the National Personnel Records Center (NPRC) responded in December 2010 that there was no record of an incident in which a Private First Class C. shot himself. A letter that month from the Department of the Army Combat Readiness / Safety Center indicated that it did not maintain records of suicides or homicides, and that the RO could contact the Army Crime Records Center if it sought further information. The January 2011 response from the Center for Unit Records Research (CURR) states that there was no record available of the "group fight" or shooting incidents described by the Veteran, though it was stated that further information might be available through a morning report search or contacting the Army Crime Records Center. The Army Crime Records Center was contacted and responded in December 2010 that the time frame for the events was outside the 40-year retention period. The February 2011 response from the NPRC indicated that there was no record of the claimed incident in which another soldier in Germany attempted suicide by ingesting pills. The Veteran underwent VA Compensation and Pension examination in April 2011. A medical history review was completed, including of the claims file, as well as a clinical interview during which the Veteran described many of his claimed in-service stressors. It was indicated by the VA examiner during the evaluation that the Veteran described vague PTSD symptoms, but the reported symptoms seemed to be related more to depressive disorder. The Veteran did not exhibit symptoms consistent with all that was required for a diagnosis of PTSD. Psychometric testing was completed, which indicated scores that were not entirely consistent with a diagnosis of PTSD. One test result in particular indicated that there was a minimal amount of depression, and the Veteran's report of increased irritability, decreased concentration and fatigue were consistent with mild depression. The examiner then diagnosed an adjustment disorder with depressive features, and alcohol dependence. The examiner observed in this regard that the Veteran reported some panic attacks and some bad dreams. He did indicate some memory loss, but it did not seem to be severe and was most likely due to problematic drinking over the years. VA treatment records show ongoing PTSD group therapy through February 2012. In reviewing the merits of this claim, initially it is noted that since mild anxiety was noted at the Veteran's pre-induction Report of Medical History in July 1964 the issue of a pre-existing psychiatric disorder is raised. The Board notes that while the Veteran reported a history of depression or excessive worry and nervous trouble of any sort and the physician's summary of the data noted mild anxiety, the psychiatric evaluation that was provided on clinical evaluation in July 1964 was normal. Therefore, the Board determines that the Veteran was sound at entry into service. Moreover, the Veteran's later report on a VA treatment record in February 2005 that he had been depressed since birth does not constitute clear and unmistakable evidence of a pre-existing psychiatric disorder to rebut the presumption of soundness. For this reason, the determinative issue is whether the Veteran has any psychiatric disorder that was incurred in military service. Having reviewed the foregoing, the Board is constrained to deny service connection for an acquired psychiatric disorder, including PTSD. The primarily claimed condition in this instance is PTSD, and recovery cannot be established on this basis. Whereas the Board acknowledges the Veteran's extensive description of in-service history and stressful circumstances, the best medical evidence before the Board nonetheless indicates that he does not presently manifest the complete clinical syndrome of PTSD. While PTSD diagnosis was mentioned in the record in November 2008 and March 2009, and the Veteran had positive PTSD screens in February 2005 and September 2006, an April 2007 PTSD screen was negative. Also, the underlying rationale for the diagnoses of PTSD was not provided on any of the medical records mentioning this diagnosis. The April 2011 VA Compensation and Pension examination effectively ruled out a diagnosis of PTSD, diagnosing other present mental health disorders. This determination followed a thorough medical history review, review of the claims file, and mental status interview with the Veteran, as well as extensive psychometric testing which repeatedly indicated that the preliminary criteria for a PTSD diagnosis were not fulfilled. Therefore, the Board has sufficient basis upon which to conclude that the absence of a PTSD diagnosis is properly grounded in fact and persuasive rationale. See, too, Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (the probative value of medical opinion evidence is based on the medical expert's personal examination of the veteran, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches). In so finding, the VA examiner had ample opportunity to review the previous mental health diagnoses of record, which themselves up to that point were strongly conflicting on the essential determination of whether the Veteran actually had the full condition of PTSD. The Board now weighs the detailed and comprehensive conclusion of the April 2011 VA examiner, based on a longitudinal case study of the Veteran's history, against the intermittent findings of those VA mental health providers that the Veteran may have had PTSD which involved considerably less searching or thorough a clinical evaluation. See Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (the Board may evaluate the underlying basis of an opinion on a medical question, and determine whether to accept such an opinion under the circumstances). Pursuant to VA law, the cornerstone of a valid claim for service connection comprises competent evidence of a current diagnosed disability. See Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), citing Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Compensation for service-connected injury is limited to those claims which show a present disability."); Hicks v. West, 12 Vet. App. 86, 89 (1998); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). See also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability."). Without competent and compelling evidence of the current disability claimed of PTSD, therefore, the Veteran's claim for service connection in this regard cannot be substantiated. The Board recognizes (as has been stated on previous occasions) that the Veteran has at least one confirmed stressor - based on his STRs, it can be presumed that he did engage in a physical altercation of some sort with a superior officer resulting in physical injury that required some suturing. However, the April 2011 examiner noted that the Veteran's problems with fighting in service were related to alcohol consumption and poor discipline. This point being addressed, given the lack of a definitive diagnosis of PTSD, there are no grounds for further inquiry into whether PTSD is etiologically related to the verified stressor, as without an underlying disability, no further inquiry on the subject of causation is warranted. Turning to the remainder of the Veteran's claim under review, while he has been diagnosed with the additional mental health condition of depressive disorder, there is no indication from the record that this condition may be associated with an incident of his military service. Rather, there was no documented depression therein, or for that matter, for several decades following service discharge. See generally, Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (the prolonged absence of medical complaints since service is amongst those factors which may be considered in determining whether a causal nexus to service is established). Nor has the Veteran propounded any theory upon which depression otherwise may be a service-related condition. The April 2011 examination report noted that for the Axis I diagnosis of adjustment disorder with depressive features that the Veteran was having difficulty with friends dying and having health problems and that he continued to drink alcohol. As noted, the April 2011 examiner also determined that the Veteran's problems with fighting in service were related to alcohol consumption and poor discipline. As previously discussed, even though the VA examiner in April 2011 did not use the term, "at least as likely as not," in addressing the Veteran's depressive disorder, the findings on the report support the conclusion that the depressive disorder was related to other factors apart from the Veteran's military service. While the anxiety that was noted on entry into service was not considered by the examiner, the Board has previously discussed that the clinical examination of the Veteran at entry into service was normal. Also the remaining treatment records do not refer to any psychiatric diagnoses or problems suffered by the Veteran in service. Therefore, the entry during the pre-induction physical in conjunction with other evidence of record does not constitute a notation of an anxiety disorder. Thus, the crucial element of a causal nexus to service has not been established. Nor for that matter is the Veteran's other diagnosed condition of alcohol abuse subject to service-connected compensation, inasmuch as it represents a pattern of behavior deemed as willful misconduct under VA law. See U.S.C.A. § 105; 38 C.F.R. 3.301(d). See also VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (June 9, 1999). It follows that there is no diagnosed acquired psychiatric disorder other than PTSD which may have an objective causal relationship to the Veteran's military service. For these reasons, the Board is denying the claim for service connection for an acquired psychiatric disability, including PTSD. The preponderance of the evidence is against the claim, and under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service Connection for Residuals of Cold Injuries STRs do not reference symptoms or diagnosis of a cold injury therein. The Veteran in his lay witness statements and through hearing testimony describes having sustained significant cold weather exposure while stationed in Hoenfels, Germany, indicating that it was during the winter months when he was sent to the firing ranges for grading of soldiers who needed to qualify. This assignment had gone on for a couple of days, with the Veteran just standing with his hands and feet freezing and hurting, and fingers swelling, when he went to the medics' tent. Here he was told that "you probably have a little frostbite" and was given gloves and sent back to the firing line. The Veteran has also described in his occupational capacity as a forward observer having frequently driven a jeep vehicle during winter months with no top and no heater causing further cold weather exposure. He otherwise describes cold weather exposure during training exercises that required him to sleep outdoors, and another occasion following a 25-mile march in which his feet became affected by the cold and repetitive stress of walking in new boots. According to the Veteran, he now had difficulty handling exposure to ice and cold temperatures, and problems with his hands turning blue and purple in the cold weather. His feet would sting and hurt in the cold, sometimes with difficulty walking. A VA Compensation and Pension examination was conducted in April 2011. The Veteran initially presented his account of cold weather exposure from during service, and described recent symptoms of tingling, and numbness of the feet. He indicated he was a diabetic, though this condition was getting better with control of the diabetes. He stated he had hand symptoms of pain that may be due to arthritis. For a period of time he had severe symptoms that had since gotten better. There was no history of cold related hospitalization or surgery, cold related trauma, or cold related neoplasm. There was no history of other cold injury, tissue loss, Raynaud's Phenomenon, or hyperhidrosis of affected parts. He described a moderate tingling sensation in the bilateral upper and lower extremities, recurrent fungal nail infections in the feet, and mild numbness of the feet. There was no change in skin thickness of affected areas. Objectively sensory examination was generally normal, with the exception of decreased pain/pinprick sensation in the lower extremities. A detailed motor exam was normal. Peripheral pulses were normal except for a decreased posterior tibial pulse. There was some onychomycosis and thickening of the right and left toenails. There was no pain on manipulation of joints in any affected area, and no edema present. The diagnosis was cold injury, bilateral feet and hands, without residuals. The VA examiner opined that the Veteran's symptoms were more likely due to diabetes mellitus than the cold injury in service. The stated rationale was that "the Veteran has minor symptoms of pain and paresthesias in the hands and more severe symptoms in the feet. The Veteran has a history of diabetes and it is more likely that his symptoms of paresthesias and pain are related to his diabetes than to the minor cold injury that he experienced while serving in Germany." The Board concludes that the evidence weighs against recovery as to service connection for residuals of a cold injury. Preliminarily, the Board does not doubt that the Veteran has some present sensory or other manifestation of a neurological condition of the bilateral upper and/or lower extremities, which potentially could be associated with a cold injury. Moreover, while the record lacks actual documentation of cold injury, for adjudicative purposes the Veteran's credible report of in-service cold injury should be taken at face value. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (where lay evidence provided is credible and competent, the absence of contemporaneous medical documentation does not preclude further evaluation as to the etiology of the claimed disorder). However, what is crucially missing at this point is competent evidence linking the Veteran's present condition to in-service injury. In other words, there is nothing to establish a causal nexus to service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."); Hickson, supra. See, too, Duenas v. Principi, 18 Vet. App. 512, 516 (2004). Rather, to the contrary, there is the opinion of the VA examiner that the relatively minor pain and paresthesias of the hands and feet are readily attributable to the alternate etiology of diabetes mellitus, rather than to the cold injury sustained in service based on the description provided. This opinion is substantiated by an in-depth physical exam, a medical history review and a clear and persuasive opinion rationale, and there likewise is not competing evidence or medical explanation proffered. Also not expressly stated in the preceding opinion, yet which cannot be overlooked, is the total absence from the record of documented symptoms, treatment or diagnosis for a cold weather injury since military service, up until the VA examination. The Board has considered the Veteran's assertions as well on the subject of causation, and he is competent to report the original cold weather exposure. Nonetheless, the questions regarding the extent of injuries sustained, the long-term consequences if any, the extent of present neurological symptoms, and whether there is any connection back to service over a period of nearly 40 years, particularly given the competing etiology of diabetes mellitus, necessarily raises fundamental medical questions that are best settled by resort to a VA examiner's opinion to this effect. Thus, the Veteran's assertions on causation are not discounted, but are ultimately outweighed by the medical evidence in this case. Accordingly, the Board is denying service connection for residuals of cold weather injury. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for an acquired psychiatric disability, including PTSD, is denied. Service connection for residuals of cold injuries is denied. ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs