Citation Nr: 1331112 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 08-08 959 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, variously diagnosed, including posttraumatic stress disorder (PTSD), bipolar disorder, major depression, depression, depressive disorder, and anxiety. 2. Entitlement to service connection for bilateral wrist joint disability. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The Veteran had active duty service from November 1990 to June 1991, as well as training in the U. S. Army Reserves. She served in the Southwest Asia Theater of Operations from January 9, 1991 to March 13, 1991. She was a member of the Reserve from July 1978 to August 2002. This appeal initially came before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a July 2007 rating decision of the VA Regional Office in Buffalo, New York. The case was remanded for further development in August 2010. Subsequent thereto, the Board reopened the claims of entitlement to service connection for bilateral hearing loss and tinnitus and denied service connection for a chronic left knee disorder, disability manifested by joint pain in the hands and knees, a skin disorder of the feet, eye disability and sinus infection, and a higher rating for post operative right ganglion cyst. The issues of entitlement to service connection for an acquired psychiatric disorder, wrist joint pain, bilateral hearing loss and tinnitus were remanded for further development. The case was remanded for further development in February 2013. Following review of the record, the issue of entitlement to service connection for bilateral hearing loss and tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran has a diagnosis of PTSD. 2. The assessment of PTSD is based on the Veteran's unverified account of stressors that are insufficient to support the diagnosis. 3. The Veteran does not have PTSD because of an in-service stressor. 4. Any other acquired psychiatric disorder, including bipolar disorder, major depression, depressive disorder, anxiety, short-term memory loss, and cognitive deficit, was first manifested years after discharge from active duty and is unrelated to service. 5. Bilateral wrist joint disability is not shown by the evidence of record. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, variously diagnosed, to include PTSD, bipolar disorder, major depression, depressive disorder, and anxiety was not incurred in or aggravated by service, and a psychosis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.306, 3.307, 3.309 (2013). 2. Bilateral wrist disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Here, the appellant was sent letters in August and December 2006 and thereafter that informed her of what evidence was required to substantiate the claims and of the appellant and VA's respective duties for obtaining evidence. The VA's duty to notify in this case has been satisfied. For these reasons, the Board may proceed to decide the appeal. The Board finds that the necessary development has been accomplished and that appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Extensive VA and private clinical records have been received and reviewed. Social Security Disability records have also been obtained for review. The issues on appeal have been remanded for further development on a number of occasions over the course of the appeal. The Veteran has been afforded VA examinations during the appeal period, that when taken as a whole, are determined to be adequate for adjudication purposes of matters decided herein. The appellant's statements have been carefully considered. In the August 2013 Informal Hearing Presentation, the Veteran's representative has requested that the case be remanded for further development as to the issue of service connection for an acquired psychiatric disorder because the more recent VA examination was inadequate. The Board finds, however, that no further examination is needed for reasons stated below. The Board is not aware of the existence of any additional or relevant evidence that has not been obtained in this regard. No further notice or assistance is required to fulfill VA's duty to assist in the development of the claims of entitlement to service connection for an acquired psychiatric disorder and bilateral wrist disability. See 38 U.S.C.A. § 5103A (a) (2); Dela Cruz v. Principi, 15 Vet. App. 15 Vet. App. 143; Smith v. Gober, 14 Vet. App. 227 (2000); aff'd 281 F.3d 1384 (Fed. Cir. 2002); see also Quartuccio v. Principi, 16 Vet. App. 183; Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (2002). As such, the claims of entitlement to service connection for an acquired psychiatric disorder and bilateral wrist disability are ready to be considered on the merits. Pertinent Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp 2013); 38 C.F.R. § 3.303 (2013). Service Connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disease was incurred in service or aggravated by service. 38 C.F.R. §§ 3.303, 3.306 (2013). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may legitimately be questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (2013). Where a veteran served continuously 90 days or more during a period of war or during peacetime service after December 31, 1946, and a psychosis becomes manifest to a degree of at least 10 percent within one year from the date of termination of service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such a disorder during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2013). Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (2013); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between the current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304 (f) (2013); see also Cohen v. Brown, 10 Vet. App. 128 (1997). Effective July 13, 2010, VA amended its regulations pertaining to service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. Specifically, 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, or a psychiatrist or psychologist with whom VA has contracted, 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, in the absence of clear and convincing evidence to the contrary, and 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. 38 C.F.R. § 301(f) (3) (2013). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is defined as doubt that exists because of an approximate balance of positive and negative evidence, which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2013). 1. Service connection for an acquired psychiatric disorder. Factual Background The appellant served in the Southwest Asia Theater of Operations from January 9, 1991 to March 13, 1991 with primary specialties of medical surgical nurse, pediatric nurse and as clinical nurse. She reportedly had with 12 years and seven months of experience as of June 1991. The Veteran asserts that she has PTSD of service onset because of traumatic stressors she experienced while in the military. In support of her claim, she wrote a long and detailed account of her feelings, fears and remembrances in a January 2007 letter related to her being activated for duty and during her deployment. She stated that she was not "able to find one specific trigger which has placed me in the state I am currently in..." but that upon being told she would be activated for Operation Desert Storm, she was "scared and terrified of not knowing what the future held for me". The Veteran's service treatment records do not refer to any psychiatric complaints, findings or diagnosis, to include on service discharge examination in March 1991. VA outpatient records dating from 2001 reflect that she underwent neuropsychological evaluation in December 2001 for complaints of inability to remember things. It was noted that during service, she had been assigned to an evacuation hospital near Oman during the Persian Gulf War. She recalled that area was sprayed all the time and that she could see "stuff dead" all over the place. The examiner surmised that this was probably an insecticide and the effects thereof. The appellant related that alarms went off all the time to signal an incoming missile but that she was repeatedly told by others not to worry about it. She denied knowledge of any specific nearby explosions from missiles. The appellant related that for the past two years, she had been having increasing difficulty with her memory and wondered if the condition was due to environmental exposure during the Persian Gulf War. She stated that nothing much had changed in her life and that she was juggling multiple roles, including parenting a teenage daughter, work that took her away from home more than she liked, multiple voluntary activities, facing surgical procedures and was concerned about her reserve being reactivated. It was noted that she had mild sleep disruption and attributed this to worries. The appellant stated that several years following the Persian Gulf War, while engaged in reserves training, she had a few dissociative episodes feeling that she was back in the Gulf Zone. It was noted, however, that she showed no indication of hyperarousal or avoidant symptoms associated with traumatic stimuli. The examiner related that there was some suggestion of posttraumatic stress syndrome but that this was highly circumscribed and not ongoing. Extensive psychological testing was performed and analyzed in detail. It was reported that stress and depression were contributing factors in her memory difficulties, and she was encouraged to seek an evaluation for psychopharmacological intervention for her apparent depressed mood. It was noted that review of her readjustment experiences following her discharge from service revealed no evidence of PTSD. Private clinical records dating from March 2003 reflect that the appellant's husband had suddenly died of a heart attack a few months before and that after he died, she had found out he was having an affair with a woman she knew and liked. She stated that daughter was going through counseling and that this was having an effect on her. It was noted that she could not eat or sleep and had been very upset and tearful and felt depressed. Depression was diagnosed for which medication was prescribed and follow-up treatment was initiated. The Veteran received group and individual therapy at a Vet Center. On the initial visit in July 2006, it was noted that she had had a hard time functioning at work recently due to short-term memory loss and flashbacks that she stated had been going on for the last eight months. It was reported that she had a nursing degree and when activated in 1990, was commissioned as a 2nd Lieutenant and assigned to an evacuation hospital near Oman. She indicated that her duties included set up and organizing triage beds for veterans coming to the hospital and that her unit accepted patients for urgent care. She related that overall, the evacuation hospital was used more or less for convalescence but that there were times when she saw 'bad injuries and war trauma.' The appellant stated that frequent alarms went off signaling incoming missiles and that this 'freaked me out' at times. She reported hearing sirens and being told repeatedly not to worry because nothing would harm her. The appellant indicated that she tried to assimilate this information with the wounded that she saw and had difficulty feeling that she was safe. On mental status examination, the Veteran's mood was depressed and she cried several times during the interview. She related that she had a recurrent nightmares and flashbacks of when she ran over her daughter accidentally when she was five. She stated that although her daughter did not have any long-term effects of the accident she still grappled with significant guilt from the incident. She said that she let things go and had difficulty keeping things up around her house, disorganized and slow at work, unable to accomplish tasks in a timely fashion, had poor short-term memory, constantly repeated herself, cried easily, was easily distracted, had a quick temper and felt herself get angry, startled easily, went to bed late and got up early, always felt jumpy, felt emotionally numb and avoided activities she had enjoyed in the past, avoided crowds, avoided news and talking about military experiences, had intrusive thoughts about the accident with her daughter but also about the Gulf War. She related that she had some contacts with reservist friends but that they did not talk about their experiences during the Gulf War. Following evaluation, Axis I diagnoses of Major Depression, recurrent, by history, and PTSD, chronic, were rendered. On Axis V, it was noted that precipitating causes were war trauma, by history, and significant losses, employment and financial issues. Statements dated in September 2006 were received from a co-worker, friend and fellow servicemember who attested to a change in her demeanor and emotional status after her deployment to Oman. VA outpatient records dating from August 2006 reflect that the appellant received continuing treatment for psychiatric disability variously diagnosed as bipolar disorder, depressive disorder, not otherwise specified, possible cognitive disorder, depression, anxiety, and rule out major depressive disorder, etc. Of record is a Medical After-Action Report for Desert Shield/Storm for the 1702nd Contingency Hospital combined with the Army's 365th evacuation Hospital. This was the Veteran's duty station in Oman. Among other things, it was noted that it was tasked to provide primary and tertiary medical care to United States and allied service members, intra-theater specialty referral service to U. S. military personnel, consultation and personnel packages as needed for aeromedical evacuation, and preventative and routine health care for base personnel. It was staffed by 50 physicians, 126 nurses, 261 medical technicians and 340 other medical and support personnel and was referred to as the U. S. Military Medical Complex Oman. It was reported that it was established in four phases from turnkey assembly and construction in October 1991 to fully operational from January through early March 1991 and redeployment from March 4 - 26 1991. It was noted that during this period, they had 91 admissions, over 5000 outpatients, dispensed over 3500 prescriptions and performed over 700 X-rays. It was reported that the primary reason patients sought treatment was for sinusitis and upper respiratory illness attributed to the dry and dusty environment, and that 27 patients were aeromedically evacuated to other medical treatment facilities because they were beyond the scope of their care. Elements of the community environment were delineated in detail and included minimal mosquito and fly vectors, as well as occasional trapping of rats, cats and mice. It was reported that no health problems were presented. It was also noted that the deployment site presented very little risk to deployed personnel, and that alerts from medical intelligence reports generally did not apply to the encampment. There were no factors that directly affected or could have affected aircrew safety or effectiveness. It was noted that although initially staffed and equipped as a convalescent center, it was ultimately tasked to handle battle casualties which proved remarkably few. The Veteran underwent a private independent psychiatric examination in April 2007 by R. P. Singh, M.D., M.B.B.S., board certified in psychiatry and forensic psychiatry, who indicated that this was at the behest of her concerned stepson. It was noted that she had been employed as a nurse until recently when she stopped working because of difficulty with cognitive functioning and concerns that she might be developing dementia. It was reported that she first received psychiatric treatment in January 2003 after her husband's sudden death subsequent to which she developed a depressed and anxious mood, sleep disturbance and irritability. Her daughter was reported to be having a difficult time around that time and that this further contributed to stress. Dr. Singh indicated records were reviewed. A comprehensive background and clinical picture were presented, to include the Veteran's complaints, and treatment history. It was noted that she wrote a three-page letter in support of her belief that she was suffering from PTSD that depicted her thought pattern to be somewhat disjointed and rambling. She stated that although she was not exposed to combat directly, she could hear gunfire and loud noises while she was stationed in the Middle East. The appellant related that she was constantly worried about her own welfare, not being able to do her job and her family's welfare. It was noted that upon her return from service, she was exposed to her colleagues being treated for 'Desert Storm Syndrome' one of whom had died from it (reported to be a heart attack). She stated that over the past year, she had not been sleeping, was having nightmares and crying spells, and experienced irritability and short-term memory loss leading to difficulty in performing her job. The Veteran related that she began to have flashbacks and dreams of Desert Storm in 1999 that included sand storms, loud plane noises, and hearing gunfire and machine guns. She said that she started to avoid crowded places because she became anxious. She expressed her belief that she was exposed to chemicals during her tour of duty and was afraid she would die. Following a mental status evaluation, Axis I diagnoses and assessment were rendered of bipolar I disorder, most recent episode mixed, in partial remission, history of cognitive disorder, not otherwise specified, and rule out mild form of PTSD with delayed onset. Dr. Singh commented that the Veteran had no known history of psychiatric illness until a few years before when she suffered from depression following the stress and sudden death of her husband. It was reported that the appellant reported a very unusual presentation of possible symptoms of PTSD, but that it was difficult to clarify this diagnosis without her being in full remission from her bipolar disorder. It was determined that the Veteran's cognitive deficits were most likely related to the mixed presentation of bipolar disorder that impacted her concentration, leading to the appearance of cognitive deficits. Dr. Singh stated that the Veteran's current bipolar disorder symptoms made it difficult for her to focus and concentrate at work and that she was not fit for duty. The Veteran was afforded an initial evaluation for PTSD compensation and pension purposes in August 2008. It was reported that the results of a social and industrial survey, her DD-214, records from a private psychiatrist and the Vet Center and other records and documents were reviewed. It was noted that she had been treated for bipolar disorder and possible PTSD and that current treatment was an anti-depressant and individual psychotherapy. Pertinent background and history were recited. It was reported that the social and industrial survey noted that while in Desert Storm, the Veteran recounted that they never knew when they were going to leave because they were afraid they would be 'blown out of the sky.' She said that she recalled feeling worried because her daughter was sick with a 103-degree fever. She recalled that while stationed at Aberdeen Proving Ground, there was a lot fighting among the women and that the unit from New York City was fighting and pulling knives on people and that this was stressful for her. She related that the possibility that she would be transferred once she got to Desert Storm was very stressful for her and that they were put on the airplane in full gear and given weapons. She said that it was scary not knowing where they were going, and what was going to happen, and that there was conflict between the Air Force and that Army. The Veteran stated that she knew the war had started when she heard planes taking off one after the other, and that the Air Force commander told them this was the case. She related that she was worried about whether she would ever come back and see her daughter again. She said she worried that they would be gassed, and that alarms went off all the time. The appellant stated that one woman was molested by a local trucker and that at night, she sometimes heard machine guns in the background. She reported that during Desert Storm, she was in constant fear. She also related that she was harassed by her commander who accused her of faking an injury. A checklist of 17 common PTSD stressors was presented to the Veteran who only acknowledged that she had experienced combat or exposure to a war zone and severe human suffering. Following mental status examination, diagnoses of bipolar disorder, and anxiety disorder, not otherwise specified, were rendered. The examiner stated that it was unclear if the Veteran met the stressor criteria for PTSD as it was noted that her stressors appeared to be related to seeing routine combat injuries and having routine military experiences. The examiner commented that bipolar disorder was the primary diagnosis and that most of her symptoms were attributable to bipolar disorder and the exacerbation of those symptoms by anxiety and PTSD traits. The examiner concluded that it was less likely than not that the Veteran had PTSD from exposure to combat injuries and sounds while serving in Oman in a field hospital unit. The Veteran was afforded a VA psychological examination in January 2011. Among other things, she reported stressor events in the military that were particularly traumatic of intense fear and feelings of horror and uncertainty. Other stressors were noted to be the deaths of or injuries to multiple family members, including grandparents, brother and daughter. Seventeen common PTSD stressors were presented to her and she acknowledged combat or exposure to a war zone and the sudden unexpected death of someone close to her. Following mental status examination, the examiner found that the Veteran met the DSM-IV stressor criterion for PTSD with military experiences and being in a combat area with associated risks of attack and injury. It was determined, however, that she did not meet the DSM-IV criteria for a diagnosis of PTSD. The examiner commented that although it might seem that the diagnostic criteria for PTSD was fulfilled, there was considerable overlap between the symptoms of that disorder and bipolar disorder. It was the opinion of the examiner that the "best fit" diagnosis in the appellant's case was bipolar disorder with traits of PTSD. A clinical report was received from T. Porpiglia, MS, LMHC, D.CEP, EFT-ADV, who stated that the Veteran had been his client for six sessions between February and April 2009 as part of a research project documenting the effectiveness of the Emotional Freedom Technique on PTSD. It was his professional opinion that she had PTSD and that her symptomatology was being covered up by medication. The appellant most recently underwent a VA examination for PTSD in May 2012. The examiner noted that the claims folder was reviewed. It was reported that she remained unemployed which she related to disability caused by anxiety. She continued to be followed as a VA outpatient for treatment of bipolar disorder. A stressor event was reported as duty in Oman where she served as a nurse to help establish a 500-bed evacuation hospital. The examiner found that this stressor met criterion A to support a diagnosis of PTSD and that the stressor related to the Veteran's fear of hostile military or terrorist activity. The examiner determined that in establishing criterion A, the Veteran 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 self or others and that her response involved intense fear, helplessness or horror. The examiner found that the appellant met criterion B to establish PTSD because she had recurrent and distressing recollections of the event, recurrent distressing dreams of the event, and acted or felt as if the traumatic event were recurring. It was also determined that criteria C, D and E were satisfied for certain aspects, but that under criterion F, she did not meet the full criteria for PTSD. Following examination, a diagnosis of bipolar disorder, most recent episode mixed, mild, was provided. The examiner commented that some of her symptoms were similar to those of PTSD but that both independent and VA-based psychiatric evaluations had deemed bipolar disorder to be her primary diagnosis. Following the 2012 VA examination for PTSD and pursuant to Board remand, the psychiatric examiner was requested to clarify whether it was as likely not that any acquired psychiatric disorder had its origins in service or as the result of any incident therein. In an addendum report dated in May 2013, the examiner provided a detailed synopsis of the results of neuropsychological and psychiatric treatment dating back to 2001 and determined that it was less likely than not that the Veteran's bipolar disorder had its origins in service or was the result of an incident during active duty. The examiner stated that it was her opinion that the Veteran had a single primary psychiatric diagnosis, namely bipolar disorder, and did not currently meet the criteria for PTSD. It was reported that this opinion was based on a complete review of the claims folder and records dating back to 2001. The examiner added that as noted in the prior evaluation report in 2012, the appellant was not treated for a psychiatric disorder during service and did not report symptoms until some time afterwards. It was also noted that at least four previous evaluations by different providers had posited bipolar disorder as the primary diagnosis. Legal Analysis An acquired psychiatric disorder other than PTSD. The record reflects that the Veteran primarily claims service connection for PTSD. However, it is noted that she has been accorded various other psychiatric and neuropsychiatric diagnoses over the years, to include bipolar disorder, major depression, depressive disorder, depression, anxiety disorder, and cognitive deficit. The Board observes that service treatment records are completely negative for complaints, findings, diagnoses or references to a psychiatric disorder or cognitive deficit, and no pertinent condition was referenced on service discharge examination in March 1991. Although she now claims that she began to have symptoms shortly after returning from the Desert Storm arena, post service training physical examination reports dating through 2000 do not refer to any psychiatric symptomatology or findings. The record reflects that there is no objective post service showing of any continuity of any psychiatric symptoms traceable to active duty. See 38 C.F.R. § 3.303. There is no clinical evidence of a psychiatric disorder until 2001, approximately a decade after discharge from active duty. At that time, the appellant was diagnosed as having depression, for which she was prescribed medication. She was subsequently treated on a continuing basis for disabilities and symptoms variously diagnosed as major depression, depressive disorder, bipolar disorder, depression anxiety, and cognitive deficit, characterized by memory loss, loss of concentration and focus, etc. As such, the Board finds that the many years between service discharge and evidence of treatment for psychiatric disability militate against a finding that the Veteran's assertions of psychiatric disorder deriving from service are credible. Her more recent contentions that she had psychiatric symptoms in service (or immediately thereafter) directly conflict with the lack of a single complaint or finding of a psychiatric disorder for so many years after discharge from active duty. Moreover, there is evidence that the first psychiatric findings or treatment came after the sudden death of her husband. Additionally, the presumption of service connection for a psychosis does not attach. This is because neither major depression nor bipolar disorder was shown to have become manifest within one year of separation from service. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board concludes that there is no reliable evidence in the record to show other than that a psychosis was not clinically indicated until years after discharge from active duty. The record reflects that in December 2001, on neuropsychological testing, it was found that stress and depression contributed to memory loss. In April 2007, Dr. Singh determined that a bipolar disorder had led to concentration problems and lack of focus leading to the appearance of cognitive deficit. As such, it must be found that the Veteran's complaints of memory loss and cognitive deficit are similarly of post service onset and unrelated to active duty. As well, there is no reliable evidence linking an acquired psychiatric disorder other than PTSD to service except for the Veteran's vague statements. The record reflects that when the appellant has been afforded VA and private examinations over the course of this appeal, it has been determined that she primarily exhibits symptoms of a bipolar disorder for which she has been receiving treatment for years. There has been no finding that bipolar disorder is related to service. Additionally, following most recent VA examination in May 2012, the examiner opined in a 2013 addendum that bipolar disorder was less likely not related to service. No other acquired psychiatric disorder, including major depression, depression, anxiety nor cognitive deficit, etc., has been etiologically linked to active service. The appellant's account of a psychiatric disorder related to service is less probative and less credible to establish a lay nexus to service. In this respect, a medical professional has the greater skill. Therefore, when considering the entirety of the evidence, the Board finds that there is neither evidence of inservice onset of an acquired psychiatric disorder or continuity of symptomatology thereafter, nor was a psychosis demonstrated within one year of separation from service. See 38 U.S.C.A. §§ 1101,1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307,3.309. The Board thus finds that service connection for an acquired psychiatric disorder other than PTSD, including bipolar disorder, major depression, depressive disorder, depression, anxiety and cognitive deficit, etc., is not warranted on either a direct or presumptive basis. PTSD The Board observes that the Veteran's primary contentions in this regard are that she developed psychiatric symptoms as the result of serving in a combat or a war zone during Operation Desert Storm as a nurse in Oman. Over the course of the appeal, she has at various times described such traumatic stressors as alarms going off all the time to signal incoming missiles that 'freaked her out', siren blaring, hearing gunfire and machine guns, being sprayed with chemicals, sand storms, being afraid of being 'blown out of the sky', and fear of being gassed that resulted in intense fear and horror leading to a diagnosis of PTSD. In this regard, the Veteran has a diagnosis of PTSD in the record. The Board must initially point out, however, that the evidence demonstrates that the she has no combat status, nor has she alleged in any of her writings or statement that she engaged in hostile action with an enemy. As well, contrary to some of her assertions to the examiners, there is no evidence that she was in a combat zone while stationed at a field hospital in Oman. The reports from that facility indicate no such action. As such, corroborating evidence is needed to support the claim of service connection for PTSD. See 38 C.F.R. § 3.304(f); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). In Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996), the Court of Appeals for Veterans Claims (Court) set forth the analytical framework for establishing the presence of a recognizable stressor which is the essential prerequisite to support a diagnosis of PTSD. These are: (1) whether the evidence demonstrates that stressful events occurred, and (2) whether the stressful events are sufficient to support a diagnosis of PTSD. As well, the diagnosis of PTSD must be rendered in accordance with 38 C.F.R. § 4.125(a) that incorporates the provisions of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In this instance, however, the Board points out that even assuming that the appellant has met the first criterion for establishing service connection for PTSD, that is, a diagnosis of such, it is found that the claim for service connection must nonetheless fail because other criteria, to include credible evidence that the claimed stressor(s) actually occurred are not demonstrated. As indicated above, the record clearly reflects that VA psychiatrists and other clinicians who have seen the Veteran since the inception of treatment for psychiatric disability in 2001, and who have extensively evaluated her during VA mental health clinic assessments over many years have found that her symptoms are consistent with psychiatric disability primarily diagnosed as bipolar disorder. However, the record reflects that a specific diagnosis of PTSD was provided by a Vet Center clinician in July 2006 and Dr. Porpiglia in 2011. Other examiners have found that she may exhibit some traits of PTSD or have some overlapping bipolar and PTSD symptomatology. The record reflects that the diagnosis of PTSD is based on the Veteran's account of traumatic stressors in a combat or war zone, to include those cited above. In actuality, however, a document of record clearly demonstrates that the appellant was stationed with a large contingent of medical personnel and support staff at a field hospital in Oman that was in a zone that was considered safe that was hundreds of miles from combat hostilities. The brief history of her unit, the 1702nd Contingency Hospital, unequivocally states that the deployment site presented very little risk to deployed personnel and that alerts from medical intelligence reports generally did not apply to the encampment. It was reported that there no factors that directly affected or could have affected aircrew safety or effectiveness. This objective evidence clearly contradicts the Veteran's assertions that she experienced such traumatic events as incoming missiles, blaring sirens, hearing gunfire and machine guns, and fear of being afraid of being blown out of the sky, etc. This obvious fabrication of the evidence undermines the Veteran's credibility and depicts her as an untruthful and unreliable historian. In this instance, there are competing opinions as to whether the Veteran has PTSD related to service. The Board points out, however, that although the Veteran has a diagnosis of PTSD, a medical opinion diagnosing such does not suffice to prove the occurrence of the claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). Although it is well established that it is the province of trained health care providers to enter conclusions that require medical expertise such as opinions as to diagnosis and causation (See e.g. Jones v. Brown, 7 Vet. App. 134, 137 (1994)), it is the Board's responsibility 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)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (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. The credibility and weight to be attached to medical opinions are within the province of the Board.). The Board points out in this instance that while some of the evidence does indeed find that she meets the criteria for PTSD, it is shown that the diagnosis was clearly predicated on unsubstantiated (and false) in-service stressors. In view of such, the Board finds that there are legitimate questions about the diagnosis of PTSD. A medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Moreover, the conclusion that the Veteran has PTSD related to service is substantially overshadowed by the findings in extensive VA and psychiatric treatment records dating back to 2001, and most recently on VA psychological examination in 2012 and 2013 that the most appropriate diagnosis in her case is bipolar disorder. The question of whether a specific event reported by a veteran as a stressor is a question of fact for the Board to decide. See Wilson v. Derwinski, 2 Vet. App. 614. (1992). Here, the Board attaches greater probative weight to the clinical findings of the skilled VA clinical professionals and less to the Veteran and her providers who diagnosed PTSD for reasons stated above. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect credibility of testimony). Greater weight may be given to one clinician's opinion than another depending on factors that include the extent to which he or she reviews prior clinical records and other evidence (See Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994)). VA has reviewed the records in this case. The Board may thus appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Therefore, the Board finds that the evidence overwhelmingly supports a finding that the appellant continues to have a bipolar disorder and not PTSD. Consequently, the conclusions of the clinicians who have found that the Veteran has PTSD related to service are of little force when compared to the amount of clinical evidence to the contrary that the appellant does not have PTSD. As such, the Board finds that the Vet Center diagnosis in 2006 and T. Porpiglia's assessment of PTSD in January 2011 are based on the Veteran's unsubstantiated stressors and are not probative. While the depiction of the reported inservice stressors and their aftermath are vivid and dramatic, they are not corroborated to any extent by the official record. As such, the claimed stressors are not confirmed. The Board has considered the appellant's lay statements in support of the claim. See Layno v. Brown, 6 Vet. App. 465,, 470. (1994). However, it is not required to accept a Veteran's uncorroborated account of her active duty experiences to support a diagnosis of PTSD (See Wood v. Derwinski, 1 Vet. App. 190, 192 (1991), especially in light of the discrepant evidence to the contrary. In summary, the Board concludes that the record does not demonstrate the criteria for a grant of service connection for PTSD. There is no credible supporting evidence substantiating the stressor the Veteran reports. Absent credible supporting evidence corroborating the claimed stressor, the regulatory criteria for a grant of service connection for PTSD have not been met, and service connection must be denied. The Board also concludes that there is no reliable and probative evidence indicating that the Veteran's acquired psychiatric disorders and/or neuropsychiatric disability, variously characterized as PTSD, bipolar disorder, major depression, depressive disorder, anxiety, memory loss and cognitive deficit, etc., are related to service or to any event therein. Furthermore, there is no showing of a psychosis within one year of separation from service. The preponderance of the evidence is against the claim and service connection for an acquired psychiatric disorder, including PTSD, must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 2. Service connection for bilateral wrist disability. Factual background The Veteran's active service records reflect that she sought treatment for right wrist pain throughout the month of February 1991 that was diagnosed as persistent DeQuervain's tenosynovitis that was unresponsive to conservative therapeutic measures. Release of the tendon sheath (tenolysis) of the right wrist was performed during the last week of that month. A Statement of Medical Examination and Duty Status in March 1991 noted a history of disease that included recurrent ganglion, right wrist for which surgery had been performed in February 1991 in Oman. The service discharge examination report in March 1991 and subsequent training physical examination reports through 2000 did not refer to joint pain affecting the right or left wrist. A claim of service connection for disabilities that included right wrist operation and pain affecting various joints, including the wrist, was received in July 2006. Subsequently received were VA and private clinical records dating from 1999. A VA outpatient report dated in March 2007 indicated that the appellant was a new patient. During review of systems, it was noted that she had pain affecting the wrists, among other joint complaints. Following examination, the assessments included intermittent left hand numbness. A neurology consultation was recommended if symptomatology persisted. In July 2007, it was noted that the appellant was first seen in May 2007 for complaints of left hand pain and numbness that was aggravated with repetitive use. It was noted that there was a history of carpal tunnel release. The findings on current examination were reported to be consistent with carpal tunnel syndrome and a wrist splint was provided. An X-ray of the hand/wrist disclosed minimal degenerative joint disease. Following examination, the assessments were symptomatic left carpal tunnel syndrome, minimal functional impairment and history of right carpal tunnel release, and mild residual symptoms without significant functional impairment. VA outpatient treatment records reflect that the appellant sought treatment through January 2008 for symptoms affecting the wrists assessed as carpal tunnel syndrome and median nerve involvement at the carpal tunnel, pronator teres and scalene, bilaterally, as well as traction injury to the median nerve on the left. By rating action dated in July 2007, service connection for right wrist ganglion cyst, status post surgery, was granted. The Veteran was afforded a VA joints examination in December 2007. She had subjective complaints of right wrist dull and constant aching and numbness. It was noted that she had bilateral carpal tunnel braces that she wore at night. The examination was negative for ganglion cyst. No other assessment was provided. Pursuant to Board remand, the Veteran underwent VA examination of the wrists in April 2012. Examination disclosed no abnormal findings and no neurologic deficit. A diagnosis of resolved left wrist neuritis was provided. The examiner further added that an opinion was not rendered relative to the wrists because the Veteran denied having any current wrist condition or problems. It was reported that she stated she was not claiming carpal tunnel syndrome or any other wrist problems and that she was treated for left carpal tunnel syndrome in 2007 but that that had resolved. Pursuant to a subsequent Board remand, a clarifying addendum to the April 2012 report was requested. The examiner stated that a wrist condition was less likely than not related to service because the Veteran denied having a wrist condition and that she had no wrist problems on the April 2012 examination. Legal Analysis The Board has carefully reviewed the evidence but finds that service connection for a wrist joint condition is not warranted. It is clear that the Veteran was treated for a nerve condition affecting the right wrist in service, variously diagnosed as DeQuervain's tendonitis and ganglion cyst, for which she underwent surgery in 1991. However, the post service record, including multiple physical examination performed in connection with her reserve training, is negative for any continuing complaints in this regard. Moreover, service connection was granted in July 2007 for residuals of right wrist ganglion cyst which is not at issue here. No inservice left wrist joint complaints or symptoms were recorded. The first post service reference to any symptomatology involving both wrists is recorded many years after service. At that time and thereafter, treatment was rendered for carpal tunnel syndrome involving both wrists, and well as median nerve involvement affecting the left wrist. However, this is approximately 16 years after the Veteran's discharge from active service. There is no opinion relating this impairment to service. There is no finding of current impairment. In the absence of evidence of continuing wrist symptoms or complaints from service, and lack of a competent clinical nexus to service or a service-connected disability, neither right nor left wrist carpal tunnel syndrome or medial nerve involvement may be attributed to service. See 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.310. Moreover, the Board points out that when examined for VA compensation purposes in April 2012, supplemented by a 2013 addendum, no abnormal wrist findings were elicited and it was determined that a left wrist neuritis had resolved. There was no diagnosis pertaining to the right wrist. The examiner explained that a diagnosis could not be provided because the appellant had no wrist disability, that she denied having a wrist disorder and that she stated that wrist problems had resolved and that she had no problems in this regard. The Board points out that a key element in establishing service connection is to show that a veteran currently has a diagnosis or symptoms of a disability for which service connection is sought. See 38 U.S.C.A. §§ 1110, 1131 and 38 C.F.R. § 3.303. In this case, there is no current clinical evidence of right or left wrist disability in accordance with applicable law. Since regulations require medical evidence diagnosing a claimed condition, the Veteran's self-assessment is not competent. 38 C.F.R. § 3.304 (2013). In the absence of objective findings of pathology, a diagnosis or complaints, the Board must conclude that there is no current reliable and/or probative evidence indicating that the Veteran has left or right wrist disability for which service connection may be granted. The Board points out that while the appellant may believe that she is entitled to a benefit simply because she had a disease or injury in service or in the past, this is mistaken. Congress specifically limits entitlement to service connection to disease or injury in cases where such incidents have resulted in current disability which is not demonstrated with respect to the wrists. In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Moreover, the Board has considered whether the reported carpel tunnel findings, when present, could have been related to service. It is concluded they were not. The record contains no opinion linking those findings to the in-service period years earlier. As noted the right wrist pathology in service has been service connected and there was no left wrist pathology in service. Thus there is no relationship to service shown for the transient carpel tunnel reported years post-service. Under the circumstances, the Board finds that the preponderance of the evidence is against the claim and there is no doubt to be resolved in the Veteran's favor. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Service connection for right and left wrist joint disability must be denied. ORDER Service connection for an acquired psychiatric disorder, variously diagnosed, to include PTSD, bipolar disorder, major depression, depressive disorder, depression, and anxiety, is denied. Service connection for bilateral wrist disability is denied. REMAND The Veteran maintains that she has bilateral hearing loss and tinnitus that are of service onset for which service connection is warranted. In the Representative's August 2013 Informal Hearing Presentation, it is asserted that a post remand VA audiological opinion requested in this regard was inadequate because the Board's instructions were not followed. The Board concurs. The record reflects that when the case was remanded in February 2013, it was specifically requested that an otolaryngologist review the entire claims folder and offer an opinion as to the origins of the Veteran's hearing loss and tinnitus. The Board observes, however, that when the case was returned to the Board, it is shown that the opinion was provided by a VA physician's assistant and not a medical doctor as directed by Board's February 2013 remand. The Court has held that if the Board proceeds with final disposition of an appeal and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In this instance, assigning the examination to a physician's assistant, and not to a VA otolaryngologist was a failure to comply with the terms of the remand. Therefore, a significant aspect of the development sought by the Board has not been accomplished. As such, the examination report is inadequate for adjudication purposes and must once more be remanded to address the deficiency. See C.F.R. § 19.9 (2013). The Veteran will thus be scheduled for a VA examination in this regard. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an examination with VA physician who is an otolaryngologist. The claims folder, and access to Virtual VA as appropriate, must be made available to the physician. The examining physician must indicate whether the claims folder and Virtual VA are reviewed. All indicated tests and studies should be performed and clinical findings must be reported in detail. The examination report should reflect consideration of the Veteran's documented medical history, current complaints, and other assertions, etc. Based on a thorough review of the evidence of record and the physical examination findings, the physician must opine with detailed and complete rationale as to whether it is at least as likely as not (i.e., probability of 50 percent or better) a) bilateral hearing loss and tinnitus had their origins in or are directly related to symptoms or incidents in service, to include any "chemical exposure therein. If not, b) whether it is at least as likely as not hearing loss and tinnitus are more likely of post service onset and unrelated to any aspect of active duty. The examination report must include well-reasoned rationale for all opinions and conclusions reached. 2. The RO must ensure that the medical report requested above complies with this remand and its instructions. If the report is insufficient or if a requested action is not taken or is deficient, it must be returned for correction. 3. After taking any further development deemed appropriate, readjudicate the remaining issues on appeal. If a benefit sought is not granted, provide a supplemental statement of the case to the Veteran and her representative before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs