Citation Nr: 1331525 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 97-12 194 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and schizophrenia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from March 1988 to March 1992. This matter initially came before the Board of Veterans' Appeals (Board) on an appeal from a May 1996 rating decision issued by the Regional Office (RO) in New Orleans, Louisiana. The case is presently under the jurisdiction of the RO in North Little Rock, Arkansas. It was most recently remanded by the Board for additional development in September 2012. It has now been returned to the Board for appellate disposition. Records in the Virtual VA paperless claims processing system and the Veterans Benefits Management System have been reviewed and considered. The Veteran testified before the undersigned in November 2010. A transcript of the hearing is associated with the record. FINDINGS OF FACT 1. It is not at least as likely as not that a psychiatric disorder was caused or made worse by military service, nor that a psychosis was present to a degree of 10 percent or more within one year of service. 2. It is not at least as likely as not that the Veteran's substance abuse disorders were caused or made worse by a service connected disability. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, including PTSD and schizophrenia, was not incurred in or aggravated by a disease or injury in service, nor may it be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. Primary substance abuse is not a disability for which service connection may be granted as a matter of law. 38 U.S.C.A. §§ 105, 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.301, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent a letter in May 2006 which explained how VA could assist him with obtaining evidence in support of his claim as well as evidence that he could submit. The May 2006 letter also explained what the evidence needed to show in order to establish service connection for a claimed disability. In June 2007, the Veteran was sent another letter which explained how VA assigns ratings and effective dates for service connected disabilities. The Veteran had ample opportunity to submit evidence and argument after receiving these notices, and his claim was subsequently readjudicated on multiple occasions, most recently in the April 2013 supplemental statement of the case. Therefore, there is no prejudice due to any defect in the timing of the notice. Additionally, at the November 2012 hearing the Acting Veteran's Law Judge outlined the issues and heard testimony pertaining to the criteria for establishing service connection. During the Board hearing, the undersigned discussed with the Veteran the issue on appeal, the evidence required to substantiate the claim, and asked questions to elicit information relevant to the claim. This action supplemented VA's compliance with the VCAA, 38 C.F.R. § 3.103, and Bryant v. Shinseki, 23 Vet. App. 488 (2010). As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. VA also must make reasonable efforts to assist the claimant with obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including paper and electronic VA treatment records and a transcript of the Veteran's testimony at the November 2012 hearing. The Board notes that at times in the 1990s the Veteran reported that he was receiving Social Security Administration (SSA) disability benefits. The SSA was contacted to obtain the Veteran's records, however in February 2009 the SSA responded that it did not have any records pertaining to the Veteran. In this case, the Veteran's service treatment records (STRs) are unavailable through no fault of the Veteran. The Board acknowledges its heightened obligation to consider carefully the benefit of the doubt rule in cases where the Veteran's service treatment records are unavailable through no fault of the Veteran. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Veteran was notified by letter that his STRs were unavailable to VA in April 1996. The Veteran was provided with multiple VA examinations in connection with his claim, most recently in March 2013. The Board finds that the examiner who performed the March 2013 examination conducted a thorough review of the evidence and provided adequate rationale for the conclusions that he expressed. Further, the Board finds that this examination was conducted in substantial compliance with the instructions that were set forth in the September 2012 remand. The Board finds that VA satisfied its obligations pursuant to the VCAA, any errors in the timing of the notice were non-prejudicial. Additionally, the Board finds that there was substantial compliance with the instructions which were set forth in the prior remands of this matter. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service connection The Veteran contends that he developed PTSD or another mental disorder as a result of his military service. Treatment records and VA examinations show a variety of diagnoses over the years, including PTSD, schizophrenia, anxiety disorder, and alcohol and drug abuse. The Veteran contends that his alcohol and drug abuse were caused by PTSD or another psychiatric disorder. Service connection may be granted for a disability resulting from disease or injury that was incurred in, or aggravated by, service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for some chronic diseases, including psychoses such as schizophrenia, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge if all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board notes that primary drug and alcohol abuse are not disabilities for which service connection may be granted as a matter of law. 38 U.S.C.A. §§ 105, 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.102, 3.303. Additionally, personality disorders are not considered congenital or developmental defects and are not disabilities for VA compensation purposes. 38 C.F.R. § 3.303(c). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirement that a current disability exists is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In general, establishing a nexus to service requires medical evidence. However, in the case of chronic diseases listed at 38 C.F.R. § 3.309, including schizophrenia, a nexus to service may be established if there is adequate evidence of continuing symptoms since service. Service connection for PTSD requires medical evidence diagnosing the disorder in accordance with 38 CFR § 4.125(a), medical evidence linking current symptoms to an in service stressor, and, in some circumstances, credible supporting evidence that the claimed in service stressor actually occurred. 38 C.F.R. § 3.304(f). Prior to July 2010, the evidence necessary to establish that an in service stressor actually occurred depended upon whether the Veteran "engaged in combat with the enemy." 38 C.F.R. § 3.304(f); See also Hayes v. Brown, 5 Vet. App. 60, 66-67 (1993). If the evidence showed that the Veteran engaged in combat with the enemy or was a prisoner of war (POW) and the claimed stressor was related to those experiences, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, his lay testimony alone was sufficient to establish the occurrence of the claimed in service stressor. If, however, the Veteran did not engage in combat with the enemy and was not a POW, or the claimed stressor was unrelated to the Veteran's combat or POW experiences, some evidence corroborating the Veteran's lay statements is required in order to establish that an in service stressor actually occurred. 38 C.F.R. 3.304(f)(2) (2009). The only other exception to the requirement for verification of an in-service stressor in effect at that time involved cases when the Veteran was diagnosed with PTSD during service and the claimed stressor is related to that service. In such cases, the Veteran's lay testimony alone was sufficient to establish the occurrence of the claimed stressor, absent clear and convincing evidence to the contrary, provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service. 38 C.F.R. 3.304(f)(1) (2009). However, in July 2010 the evidentiary standard was relaxed. The current 38 C.F.R. § 3.304(f)(3) states: 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 the 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 in service stressor. For purposes of this paragraph, 'fear of hostile military or terrorist activity' means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. In this case, the Veteran's DD-214 shows that he served in Southwest Asia and was awarded the Combat Action Ribbon. Therefore, to the extent that the Veteran's claim addresses PTSD, exposure to a stressor is conceded. The Board also notes that in the case of combat Veterans, satisfactory lay or other evidence that a disease or injury was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions, or hardships of such service, even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Facts The Veteran related that he was treated for an anxiety disorder in service. The Veteran reported that he was treated for alcohol abuse in service and directly after service. After service, in 1993 the Veteran sought treatment for alcohol abuse. He denied prior detoxification or rehabilitation admissions and denied seeking treatment for substance abuse at any prior time. He reported that he drank a half of a case to one case of beer and mixed drinks during his last episode of binge drinking. He reported that he drank since age 20. He reported a history of alcohol related blackouts and hallucinations. He denied suicidal thoughts or any prior suicide attempts. The diagnosis noted during this admission is alcohol dependence. The Veteran was admitted to a VA Medical Center for inpatient substance abuse treatment in March 1993. He reported that he had been drinking since age 19, at least a case a day. He stated his alcohol abuse got worse after leaving the Marines. He denied receiving prior treatment for substance abuse. He reported that his alcohol use caused problems at work, with family, and financially. He reported 10 to 15 public intoxication charges. He did not report any past psychiatric treatment. A mental status examination was normal. The Veteran denied any mood problems. Personality testing fell within the normal range. The only diagnosis at discharge was continuous alcohol dependency. A document from June 1993 indicated that the Veteran came in to the VA Medical Center for substance abuse treatment. He was acutely intoxicated at the time he came to the facility and notes indicate that he was screaming and shouting. The admission note states that the Veteran was belligerent and had at least three other visits with alcohol related problems and violent behavior, at least one of which had led to a psychiatric admission. The physician was unable to obtain a coherent history from the Veteran. He was delirious. The physician felt he needed to be held involuntarily, but is unclear whether he was actually admitted. Notes from June 1993 indicate that the Veteran reported that he was admitted for detoxification in February 1993 and went to a substance abuse treatment program in March 1993, which he completed in April 1993. The impressions were chronic alcohol abuse and chronic alcohol dependency. He reported that he first used alcohol when he was 19 and he realized that he had a problem when he was 23. He denied the use of other drugs. He reported that he drinks beer and mixed drinks until he passes out and his last drink was the prior day. He reported a history of blackouts but no hallucinations or seizures. He reported he tried to kill himself by getting hit by a car in December 1992. He reported that he only did this when he was drunk. He denied he was suicidal at the time he came to seek substance abuse treatment. A sheet entitled "discharge instructions" indicates that the Veteran was diagnosed with depression, an alcohol related disorder, and dependent personality traits. A treatment plan dated in August 1993 documented that the Veteran presented with the problem of depression. He was noted to have ineffective coping skills. He reported that he last went through a detoxification program in June 1993. He had last used drugs or alcohol the day before admission. The Veteran was brought to the VA Medical Center by police in January 1994 after an altercation with his girlfriend, reportedly to avoid going to jail. The Veteran reported that he left a prior substance abuse program against medical advice and had no intention of following the treatment plan. He reported that his threats to staff were "kidding" and that he was just trying to get attention. The decision was made to discharge the Veteran. Diagnoses were polysubstance abuse and dependent personality disorder. In May 1994 the Veteran was admitted for medical detoxification. He admitted to also smoking marijuana. Multiple prior admissions to the detoxification unit were noted. The Veteran was diagnosed with chronic alcohol abuse, alcoholic liver disease, probably alcoholic hepatitis, and personality disorder. In July 1994 the Veteran presented to the emergency room complaining of paranoid ideas, hallucinations, and suicidal and homicidal ideas. A physician determined that the Veteran should be admitted to the hospital involuntarily. However, apparently this had to be approved by the coroner, and the coroner did not agree with the determination. Nonetheless, it does appear that the Veteran was at the hospital for a few days and underwent medical detoxification. The preliminary diagnosis was acute psychosis, and this is the earliest mention of psychosis in the Veteran's treatment records. Diagnoses at discharge were alcohol abuse, alcoholic liver disease, and personality disorder. In December 1994, the Veteran was admitted to a VA hospital due to suicidal and homicidal ideation, and given diagnoses of schizophrenia and alcohol abuse. This hospitalization lasted approximately one month, with significant improvement over the course of treatment, including antipsychotic medications. At the time of this episode, he reported a prior hospitalization in 1992 for alcohol abuse directly after service. The Veteran reported that he was shot at with guns and bombs in service and saw people get killed but did not directly participate in any fighting, although he witnessed it. He said that he had dreams and flashbacks about sleeping while he was in the Marine Corps and then wakes up in a cold sweat. At the time of his discharge he was in good spirits without any hallucinations of homicidal or suicidal ideations. In December 1995 he was again hospitalized with a diagnosis of schizophrenia, and was discharged irregularly two days later when he could not be found by hospital security. An outpatient record, undated, apparently transcribed by a medical student, showed diagnoses schizophrenia and history of alcohol abuse and PTSD. The Veteran reported that he was no longer having hallucinations. He reported bad dreams of people shooting him and breathing chemicals. He felt that God called him to fight in the Gulf War. A February 1996 treatment record reflected that the Veteran reported having nightmares of the Gulf War. He had not taken his antipsychotic medication because he was drinking alcohol with a friend the prior night. That evening, he felt depressed. However his described his mood as "happy" at the time of the evaluation. The Veteran was referred to the mental health clinic. The Veteran was hospitalized again for about five weeks in July 1996, with diagnoses of schizophrenia with alcohol abuse. He reported that he recently had been shot at and it was making him feel anxious. He had been drinking heavily and was brought to the hospital by a neighbor. He described anxiety attacks with no autonomic symptoms and thoughts that he was being exposed to poisonous chemicals. He reported that these attacks began while he was in the Persian Gulf. He reported that he was run over in 1993 after lying down in front of a car as a suicidal gesture (previously, he reported he did this to get attention). He was diagnosed with schizophrenia in 1994. At the time of his admission, he endorsed paranoid delusions. By the third day, the Veteran denied any further suicidal thoughts. He was not hearing voices but was concerned about his anxiety level. His condition was greatly improved at the time of discharge. Recommendation was made for follow up substance abuse treatment. The Veteran did not participate in the substance abuse treatment program due to moving out of the area and he was disenrolled from the treatment program in January 1997 with a note that he had not attended the program in 1996. In October 1996 the Veteran was evaluated at a VA Medical Center for service connection for PTSD. He reported that he was abused as a child. His family history was positive for schizophrenia. The Veteran reported that he was receiving disability benefits reportedly for schizophrenia. The Veteran was in the Persian Gulf for over seven months. Records did not reflect any combat experience but the Veteran reported that he was in combat and was shot at by the enemy as well as friendly fire. Since his service, he had been hospitalized several times. This began right after service in 1992 when he was reportedly asked by the military to go into treatment for substance abuse. He completed the program but became increasingly paranoid. He was hospitalized in late 1994 and early 1995 with diagnoses of schizophrenia and alcohol abuse. He was also hospitalized in December 1995 and July 1996 but left against medical advice in both cases after two days. At these times, he was also diagnosed with paranoid schizophrenia and alcohol abuse. At the time of the interview, the Veteran reported that he felt he could read minds and other people could read his mind. He did not report any dreams or re-experiencing of traumatic war events. His most traumatic memory is related to a belief that he may have been exposed to poison gas while in the desert. Apparently, during a drill he did not believe it was just an exercise and believed he was going to die. He reported that he woke up at night sweating and anxious but did not recall any distressing dreams. He felt others were watching him and talking about him and did not feel safe outside the VA hospital. Objective findings on evaluation were that the Veteran was fully oriented without any evidence of psychosis, however, his speech was pressured. There was some tangentiality, but for the most part his thought processes were logical and intact. The delusion about mind reading was very strong and very distressing to him. He had paranoid thoughts about the motivations of others. The examiner felt the majority of the Veteran's distress was related to his delusional thought process and not PTSD. Psychological testing showed over reporting of symptoms on three tests with validity scales. The Veteran scored above the cutoff range on a PTSD measure, but that test did not contain any validity scales and the examiner noted that the results should be interpreted cautiously. The examiner diagnosed schizophrenia and alcohol abuse and opined that the Veteran's substance abuse made his schizophrenia unstable and this was more than sufficient to account for his symptoms. A document entitled "Medical Certificate" dated in September 1996 indicates that the Veteran was diagnosed with PTSD, schizophrenia, and headaches. It is unclear what situation this form is associated with or what type of assessment was done at that time. The Veteran was admitted to the hospital in November 1996; he was intoxicated at the time. He complained about girlfriend problems and suicidal ideation. It was noted that the Veteran had a past history of schizophrenia and panic attacks and he claimed that he had PTSD. There were no complaints of psychotic symptoms. During the hospitalization, the Veteran was noted to be somewhat paranoid. He reported that he had trouble sleeping due to anxiety. He reported that although he did not have hallucinations now, he experienced this symptom two years ago. The Veteran reported that he drank about 12 beers a night and 40 ounces of beer during the day. He also occasionally smoked marijuana. Discharge diagnoses were chronic schizophrenia, substance abuse, and panic attacks. The Veteran was admitted to the hospital again a couple of weeks later after he complained of suicidal ideation. The Veteran was intoxicated at the time. It was noted that this had been a long term pattern for the Veteran. When he is intoxicated his mother or girlfriend will not let him stay with them so he has no place to go and comes to the hospital. He went through detoxification and after that he denied suicidal thoughts. He told staff that he was just drunk at the time of admission. It was noted that the Veteran did not want to cooperate with treatment at the VA Medical Center and wished to instead be seen at a private facility. The Veteran was discharged after three days. Discharge diagnoses were alcohol and drug abuse and personality disorder NOS. The Veteran was admitted to the hospital in December 1996. It was noted he had three admissions for similar problems in the past four weeks. He just recently left the hospital against medical advice several days before this admission. The Veteran stated that he had PTSD and alcohol dependency. It was noted that the Veteran had no real desire to harm himself or others but rather uses these statements as catch terms to get admitted to the psychiatry ward. During his stay, he spent much of the time in bed, made several calls to his girlfriend, and was smiling and joking with staff and on the phone. At the time of his discharge the Veteran denied hallucinations or suicidal or homicidal ideas. Discharge diagnosis was schizophrenia. Later in December 1996 the Veteran was admitted to a private hospital. Personnel from the private hospital tried to arrange follow up care for the Veteran at the VA Medical Center, but it was noted that the Veteran had recently been barred from outpatient and inpatient services due to threats against staff and noncompliance with treatment recommendations. It was noted that out of the last five admissions the Veteran left against medical advice twice, and he had four "emergency" admissions to the psychiatric ward within the last two months. Diagnoses were rule out alcohol dependence, alcohol abuse, and noncompliance with treatment. In January 1997 the Veteran came to the hospital with complaints of voices telling him to kill someone. Prior to coming to the hospital, he drank a quart of beer. Diagnoses at that time were schizophrenia by history and alcohol dependence. Because the Veteran had been barred from receiving service at the VA Medical Center due to disruptive behavior, he was turned over to legal authorities for disposition. The Veteran tried to obtain services at the VA Medical Center throughout 1997 and although there are notes that he was barred, he was admitted to the hospital in July 1997. He had reported panic attacks and suicidal ideation. It was noted that the Veteran had at numerous times abused the system. He had a number of admissions complaining of suicidal ideation with later admission that he was using that as a way in the door when he had reasons of his own for wanting to be hospitalized. The Veteran had been admitted for suicidal and homicidal ideation, but after evaluation by staff it was determined that the Veteran was not suicidal or homicidal and that he had said this because he knew it would get him admitted to the hospital. It was noted that the Veteran had a court date upcoming shortly and the Veteran had previously used the hospital to avoid going to court. The Veteran was not assessed to have any significant psychological problem that could be addressed at that time. He was discharged so he could make his court date. Discharge diagnoses were alcohol and cannabis abuse, rule out panic attacks, rule out PTSD. In August 1997 the Veteran was processed for involuntary admission after making threats to start killing people and then kill himself. He reported that once he starts he will kill anyone who tries to stop him. It appears that the Veteran was seen at the VA Medical Center emergency room, tried to leave the hospital. Plans were made to transfer him to a private hospital but it does not appear that the Veteran was found by the police after he left the hospital, although this is somewhat unclear. Diagnoses were acute exacerbation of chronic psychosis and alcohol abuse. In September 1997 there is another document indicating that the Veteran was to be detained involuntarily and transferred to a private hospital after coming to the VA Medical Center emergency room with a knife and threatening people. It is unclear whether the transfer actually occurred. The Veteran submitted a written statement in September 1997. He reported that he was shot at in service and saw others wounded and killed by enemy and friendly fire. He reported having nightmares about his experiences two times a month over the past five or six years, and that he thought of the events while awake a few times per week. He reported flashbacks of not being able to find his gas mask, and people screaming and asking "why did you kill me?" He had less interest in social activities and exercise. He did not trust people. After the war he became nervous and hyper alert. He startled easily. He had trouble sleeping. He has nightmares and difficulties with memory. He avoids activities that remind him about the war because he gets nervous and anxious when he thinks about it. He felt that he was unable to work due to his anxiety. He felt that his substance abuse was due to his anxiety. In 1993 he tried to commit suicide by lying in front of a car. He tried to commit suicide twice in 1996 but was unsuccessful. He has become violent at times so that the police have been called. He believed that he was totally disabled by PTSD. In December 2007, the Veteran was admitted to the hospital. He was intoxicated at the time. The physician assistant who dictated the discharge summary noted that the Veteran had multiple prior admissions with complaints of suicidal ideation, PTSD, panic attacks, and substance abuse, and that the only substantiated problem was substance abuse. He left the hospital against medical advice after two days. Discharge diagnoses were alcohol abuse and personality disorder NOS. A letter from a social worker dated in October 1998 indicated that the Veteran had been in treatment since 1997 and was diagnosed with paranoid schizophrenia, anxiety disorder not otherwise specified (NOS), alcohol dependence, and personality disorder NOS with paranoid and antisocial traits. He had not been seen since June 1998. A private treatment record dated "11/17" (no year) indicated that the Veteran was diagnosed by a medical student with alcohol intoxication and abuse, psychosis not otherwise specified (NOS), PTSD, and another anxiety disorder. The Veteran was reexamined for compensation and pension purposes by Dr. L. H. in July 1998. He reported a positive family history of mental illness and a prior diagnosis of schizophrenia, for which he was receiving disability benefits. There were some discrepancies concerning whether the Veteran was in combat in Southwest Asia; records indicated no direct combat but the Veteran reported being shot at and taking many prisoners. Since his discharge, he had many psychiatric hospitalizations. He was last examined for compensation and pension purposes in October 1996 so the history since that time would be summarized. In December 1996 the Veteran was hospitalized for drinking binges. He was noted to have a history of using psychiatric hospitalizations to avoid legal troubles. He was admitted to the detoxification program in July 1997 and discharged after three days. He had 16 beers and said he was suicidal. He was admitted to the detoxification unit again in September 1997 and was discharged against medical advice two days later. He was again admitted to detoxification at VA in December 1997 for two days. At all of these times, the discharge diagnoses were schizophrenia and alcohol abuse with no mention of PTSD. It was noted that there were discharge orders that appeared to be from a private hospital showing a diagnosis of PTSD but it was unclear when the diagnosis was given or under what circumstances. The Veteran reported that he was anxious and having difficulty as a result of having been in the Persian Gulf. He denied having hallucinations at the present time. He reported difficulty falling asleep and suggested that he was paranoid. The last time he wanted to commit suicide was six months ago. After he gets paid, he drinks a six pack to half a case of beer. He was aware that he had been diagnosed with schizophrenia but he felt that he had PTSD. He did not report any dreams or re-experiencing of traumatic events in the current year. His most traumatic memory was his belief that he was exposed to poison gas in the desert. During a drill he felt anxious and like he was going to be killed. He woke up at night sweating and anxious. Although he did not remember any distressing dreams, he felt this was due to his Persian Gulf service. He believed people, especially the police, were watching him and talking about him and treating him unfairly. Someone had shot him in the past so he feared for his own safety. His most recent encounter with police was after he got angry and broke a window while intoxicated. The Veteran was alert and fully oriented with no evidence of psychosis. However, his speech was pressured. There was some tangentiality, but for the most part his thought processes were logical and intact. He was notably paranoid. The majority of his distress seemed to be caused by his delusional thought processes rather than PTSD. Psychological testing was largely invalid due to over reporting of symptoms. The examiner concluded that the Veteran did not have PTSD. He was noted to be an unreliable informant in view of the fact that the information he provided changed from test to test setting. The Veteran was experiencing anxiety that appeared to be the result of his delusional thinking and paranoia. The examiner believed the evidence supported a diagnosis of paranoid schizophrenia. In addition, he had a history of noncompliance with substance abuse treatment and with psychiatric treatment. The Veteran's schizophrenia was exacerbated by his alcohol abuse, and this accounted for his symptoms. He was diagnosed with paranoid schizophrenia and alcohol abuse by history. The Veteran had a short hospital stay in June 1999, but left before he could be evaluated by the psychology service. It was thought provisionally by a psychologist that the Veteran had either schizoaffective disorder or bipolar disorder with psychotic features. In July 1999 the Veteran was admitted to the hospital again. Discharge diagnoses were depression with suicidal ideation, psychosis, and substance abuse. It was noted that the Veteran was acting very irrationally at the time of his admission, but improved and was cooperative during the course of his stay. In November 2001 the Veteran was admitted to the hospital after using alcohol. He stated that he had run out of medication. He improved over the course of his hospital stay. Discharge diagnoses were paranoid schizophrenia, depression, substance abuse, and personality disorder NOS. In December 2001 the Veteran was admitted to the substance use rehabilitation program. He reported substance abuse since the age of 19 with the longest period of abstinence when he was stationed in Saudi Arabia and alcohol was not available. He denied having a problem with other drugs although he admitted using marijuana and cocaine. He reported blackouts, depression, paranoia, and palpitations related to his alcohol use. Outpatient diagnoses in 2002 included schizophrenia, alcohol dependency, schizoaffective disorder, and depression. In October 2002 the Veteran was admitted to the hospital again after reporting that his anxiety was getting worse. It was noted that the Veteran had been incarcerated numerous times for various offenses. Discharge diagnoses were schizoaffective disorder and polysubstance dependence. The Veteran was admitted to the hospital again in May 2003. He reported drinking about six beers daily. He reported he was using his medications but not as prescribed. Drug screen was positive for alcohol and marijuana. Discharge diagnoses were alcohol abuse, marijuana abuse, and personality disorder NOS. The Veteran was reexamined by Dr. L. H. for compensation and pension purposes in September 2003. Since his last compensation and pension examination, there had been no psychiatric hospitalizations. The Veteran was treated as an outpatient. He had a history of substance abuse treatment, and had excessively used alcohol, crack, and marijuana. He reported (for the first time) that the most stressful event that took place while he was in Southwest Asia was another soldier killing himself. He reported that he thinks about this and then starts drinking and becomes suicidal. He also reported being scared thinking about chemical weapons. He reported that he had fired upon the enemy but did not know if he had killed anyone. He reported that his anxiety was getting worse but he was not currently having delusions. The Veteran reported severe depression and extreme anxiety. He denied any hallucinations or homicidal or suicidal ideation presently. He reported a history of one suicide attempt and history of suicidal ideation subsequent to drinking alcohol and using street drugs. He was oriented but had difficulty with attention and calculation. Memory was unimpaired and the Veteran was able to abstract. He reported a history of three suicide attempts beginning in 1993 after drinking. He stated his mood was anxious and his affect was appropriate to the context and setting. His speech was pressured. He reported trying to commit suicide by overdosing on antidepressant medication on one occasion. He reported a history of excessive use of alcohol since age 19. He reported three rehabilitation attempts for alcohol and marijuana and crack use. He last used street drugs six or seven months ago. He reported difficulty falling asleep about half the time. The examiner diagnosed paranoid schizophrenia (primary diagnosis), alcohol dependence, self-reported in remission, cannabis dependence, self-reported in remission, and mild PTSD (related to the suicide of the other soldier in the Persian Gulf), and personality disorder NOS with prominent dependent, avoidant, and passive aggressive traits. The Veteran was examined again, by a different provider, also in September 2003, approximately two weeks after the previous examination. At that time, the Veteran reported that he started having anxiety attacks while he was in the Persian Gulf War. He attributed this anxiety to awkwardness in social situations and it caused him some difficulty in military formations. When he was in the reserves, he felt his rank should have been higher. He said that his service in the Gulf War was basically characterized by some chronic dissatisfaction, but no unusual exposure to life threatening situations. He reported that he did not receive any mental health treatment until after he returned to the United States in 1993. He claimed that he told a Navy corpsman that he wanted to kill himself but he did not receive any specific treatment. At this time, he was not on active duty but was in the Individual Ready Reserve. They eventually told him that he had an alcohol problem and he completed a 90 day substance abuse treatment program after which he was sober for about six months before relapsing. In 1995, he began having some delusional symptoms accompanied by severe derealization. About a year ago he was incarcerated for 90 days for criminal property damage. While he was in jail he felt his medications were not handled properly and he started having feelings of being threatened and premonitions. He did better once his medications were resumed. The Veteran avoided eye contact during the interview. His general demeanor was rather serious but he did get fairly talkative. His mood was initially wary, and his affect was restricted. He reported that his sleep was variable. He denied any hopelessness or suicidal ideation and stated that these symptoms usually only occurred when he was drinking. His speech was normal in rate but somewhat rambling and occasionally rapid and difficult to understand. He went into a lot of long and somewhat tangential explanations of his previous behavior. There were no current psychotic symptoms. He was fully oriented. Memory was normal. There were some limitations in judgment and insight but otherwise no cognitive impairments were noted. The examiner specifically noted that he review the examination which had been done earlier that month, in addition to the other records in the claims file. He diagnosed psychotic disorder NOS, alcohol dependence in remission, cannabis dependence in remission, probable personality disorder NOS. He did not believe that the Veteran had PTSD and he did not believe the Veteran's psychiatric problems were the result of his military service. The Veteran was hospitalized in January 2004 shortly after being release from jail. He reported that he was about to have a nervous breakdown. It was noted that Veteran had not filled his medications in a few months. He reported that he had been drinking alcohol. Discharge diagnoses were alcohol abuse, marijuana abuse, and personality disorder NOS. Another opinion was obtained from a different examiner in January 2004, based on a review of the record and the prior examinations. An in-person examination was not deemed necessary since the Veteran was just discharged from the VA Hospital a week earlier. The examiner noted that the Veteran had four prior compensation and pension examinations and had seen numerous mental health providers as a part of inpatient and outpatient treatment as well as during substance abuse treatment programs in the past. The examiner summarized the prior history and diagnoses by other providers. He noted that the Veteran's military history had been previously documented but there were numerous inconsistencies in what the Veteran had reported. In most sources, he actually denied life threatening trauma. The Veteran's documented problems during military service were alcohol related, although he had at times made inconsistent reports of treatment of some type during service. He apparently completed alcohol treatment while in the military, returned to duty and completed his tour, and then resumed using alcohol. After service, he reported treatment for alcohol abuse and detoxification at a VA Medical Center, a private facility, and then at another VA Medical Center in December 1994. Since 1995, the Veteran had numerous presentations and admissions under the influence of alcohol, a situation which would appear to have complicated diagnostic impressions in the past and led many providers to provide a diagnosis of schizophrenia. However, records of his hospitalization in May 2003 and January 2004 do not indicate the presence of any diagnosis of psychosis or schizophrenia. Records clearly indicate that any psychosis was believed to be related to his ongoing substance abuse problems. Available evidence indicates that the initial diagnoses were schizophrenia and alcohol abuse; however, current information strongly argues against a diagnosis of schizophrenia. While there is some support for past psychosis, the evidence indicates that it is most likely substance induced, and thus not schizophrenia. The examiner noted that the Veteran had variable presentation at times of evaluation, sometimes reporting hearing voices, at other times saying he has not for two months at a time, a 1996 entry indicated that the Veteran was depressed and suicidal the previous night but felt happy right now on the day after the report. As a result, there have been differences of opinion regarding his diagnoses and he has received a variety of diagnoses in the past, including schizophrenia, psychosis NOS, depressive disorder NOS, dysthymic disorder, alcohol dependence, cannabis dependence, schizoaffective disorder, personality disorder NOS, dependent personality disorder, noncompliance with treatment, and even PTSD. Most recent psychiatric hospitalizations in January 2004 did not support a diagnosis of active psychotic process of schizophrenia, but rather alcohol dependence, cannabis abuse by history and personality disorder NOS. Following a brief hospitalization in May 2003 a conclusion was noted that the previous diagnosis of schizoaffective disorder was felt to be alcohol induced. The diagnosis of schizophrenia was removed from the problem list in the computer in 2000. Review of the most recent psychological testing showed the results were overall invalid due to over reporting. The pattern of responses was not consistent with an active psychotic process. The examiner noted that the undated (presumably 1997) private hospital discharge order diagnosing PTSD was written by a medical student and not a mental health professional. The current review does not support a diagnosis of PTSD. The examiner noted that the Veteran had seen numerous providers over the years at the VA Medical Center and diagnoses of PTSD were sparse. The examiner noted that while Dr. L. H. diagnosed PTSD at the first September 2003 examination, her previous evaluation in 1998 had specifically indicated that the evidence did not support the presence of PTSD and she did not address this inconsistency in her report. The only other PTSD diagnosis was on a one page handwritten order apparently from a private hospital, among a list of other diagnoses. The sheet does not validate any symptoms which would justify any of the diagnoses listed, including PTSD. Additionally, this diagnosis was made by a medical student and not a psychiatrist or psychologist. The examiner concluded that the evidence did not support a diagnosis of either PTSD or active psychotic or schizophrenic process. In addition, the evidence supported the conclusion of Dr. R. in September 2003, that the Veteran's mental health problems are not related to military service and there is no documentation of any mental disorder, whether correct or incorrect, until two and one half years after separation. There is ample evidence during the two most recent hospitalizations that indicates the lack of support for a diagnosis of schizophrenia or active psychosis. The vast majority of the information supports a principal diagnosis of alcohol dependence, which has continued to the present of January 2004. As previously noted, the Veteran's self-reports have been widely inconsistent and indeed contradictory at times in different evaluations which would appear to account for the wide disparity in diagnostic impressions in the past, including the difference in diagnosis between Dr. L.H. and Dr. R. which were conducted within the same month but also among other diagnoses he has received in the past. For example, at times the Veteran denied experiencing life threatening trauma during the Persian Gulf War but at other times claimed he was in combat, shot at, etc. Evidence from initial evaluations supported a principal diagnosis of alcohol issues only with a reported diagnosis of schizophrenia approximately two and a half years after the Veteran's service. Although there is some support for psychosis in the past, the evidence strongly supports the more recent conclusions of the doctor who saw the Veteran at his two most recent hospitalizations that any psychosis was related to substance use issues and was not schizophrenia. Given the ongoing nature of his failed sobriety in the past, including evidence of use to the point of intoxication during the last month which led to psychiatric admission, the diagnosis of alcohol dependence is supported as the principal diagnosis, with evidence that he had treatment in the military and at various other facilities since that time. The Veteran has continued to drink in spite of medical and legal problems associated with alcohol use. He failed to complete substance abuse treatment programs at VA in 2001 and 2002. There are numerous indications of admissions for medical detox for alcohol and also reports of enrollment in other programs. The diagnosis of cannabis abuse appears in early full remission. The examiner stressed that the two most recent psychiatric admissions both resulted in the principal diagnosis of an alcohol problem. His behavior during these last two admissions did not support any evidence of psychosis although the staff had much longer periods of observation and evaluation time available. The examiner noted elevated alcohol levels on numerous instances presenting to the VA Medical Center from 1996 through 2004. In addition, there was indication of past cocaine and marijuana abuse. The examiner diagnosed alcohol dependence, severe (principal diagnosis), psychosis NOS, probably substance abuse related in remission, cannabis abuse in apparent early full remission, and personality disorder NOS. Treatment records show that the Veteran showed up to the VA Medical Center intoxicated on multiple occasions and reported at times smoking marijuana. At times, he reported being suicidal and homicidal. In January 2004 the Veteran denied substance abuse and psychotic symptoms. He reported experiencing anxiety. Diagnoses were alcohol induced mood disorder and personality disorder. In April 2004, reportedly two days after he got out of jail, the Veteran was admitted to the hospital and discharged with diagnoses of polysubstance dependence, psychosis NOS probably due to substance abuse, and personality disorder NOS. It was noted at the time of that admission the Veteran's drug screen was positive for alcohol, marijuana, and cocaine. 12 prior admissions for substance abuse or psychiatric reasons were noted. He was enrolled in the substance abuse treatment program in May 2004 after being released from the hospital. At that time, he reported that he was treated for alcohol abuse while he was in the military and that he had combat experience. He had multiple legal problems in the past possibly related to alcohol use including drunk and disorderly, resisting arrest, assault, and theft. He reported past use of marijuana and cocaine. The Veteran reported that symptoms associated with his alcohol use included paranoia, palpitations, hallucinations, memory impairment, and depression. Records from the alcohol detoxification and drug abuse treatment program show a diagnosis of alcohol and cocaine dependence. Diagnoses shown on VA examination in June 2004 are alcohol dependence, psychosis NOS, likely secondary to substance use, cannabis abuse, and cocaine abuse. It was specifically noted that the Veteran's symptoms did not support a diagnosis of PTSD or other mental disorder related to the Veteran's military experiences. Diagnoses shown in July 2004 are polysubstance abuse and mood disorder. A week after a visit to the Medical Center in July 2004, the Veteran was arrested as a result of behavior under the influence of alcohol. The Veteran's aunt stated that he is a different person when he drinks and he becomes angry and violent at times. Subsequent inpatient and outpatient treatment notes in 2009 include diagnoses of schizoaffective disorder, alcohol induced mood disorder, alcohol dependence, anxiety disorder NOS, and personality disorder NOS. The Veteran was admitted to the hospital for eight days in August 2009 after drinking excessive amounts of alcohol. The examiner noted 23 prior hospitalizations for psychiatric reasons at that VA Medical Center and 29 total hospitalizations at VA facilities for psychiatric or substance abuse related issues. The Veteran's most recent hospitalization was in March 2008 with discharge diagnoses of alcohol abuse, history of polysubstance abuse, nicotine dependence, history of schizoaffective disorder. He admitted to drinking a six pack or more of beer after work. He occasionally used marijuana. After detoxification and during the course of the hospitalization, his anxiety was less and his mood was improved. Admission and discharge diagnoses were schizoaffective disorder, anxiety disorder NOS, and personality disorder NOS. A diagnosis of PTSD was added to the "problem list" in the Veteran's VA treatment record in August 2010. The Veteran testified at a hearing before the undersigned Acting Veterans Law Judge in November 2010. At his hearing he testified that while he was in Southwest Asia he saw dead bodies and got shot at. On one occasions he was in a fire fight, and subjected to friendly fire, and there were some casualties. He was really afraid of chemical weapons. He did not have any problems killing the enemy, or calling the artillery, or shooting, but he was afraid of the possibility of a chemical weapons attack. When he got back to the United States he did not have much fear about life and death and started drinking more heavily. He felt he should have been awarded a higher rank. After he got out of the Marine Corps he was in the Navy Reserve for a short period of time, but he stopped going to formations because it was too stressful. He first sought treatment for a psychological problem in 1993. He had been told he was diagnosed with PTSD and took some classes for it. He was in the hospital several times for alcohol related psychological problems. He claimed that he was told he had a psychological condition that was due to his military service by a VA health care provider. The Veteran was admitted to the hospital again in January 2011 after he was discharged from a substance abuse treatment program for an infraction. He did not report any hallucinations at that time. He reported that he was doing well and his anxiety had lessened with the addition of a new medication. Discharge diagnoses were cocaine dependence, marijuana dependence, alcohol dependence, schizoaffective disorder, and personality disorder NOS. VA treatment records from 2011 reflect treatment for substance abuse and psychiatric problems. The Veteran participated in group therapy for substance abuse and PTSD. He participated in a vocational rehabilitation program. Treatment notes reflect diagnoses of schizophrenia, PTSD, alcohol dependence in remission, and cannabis and cocaine abuse in remission. The "problem list" also reflects a diagnosis of adjustment disorder. The Veteran reported that he was no longer using drugs and alcohol and had been sober since early 2010. He was feeling better. It appears that the primary treatment modality during this time was various forms of group therapy. Several records reflect that the Veteran appeared to be upbeat or in good spirits. The Veteran was examined again for compensation and pension purposes in June 2011. At that time, the Veteran reported that while he was in the Persian Gulf he was fired upon and saw dismembered bodies but went on to state "Everything was just so generalized. Missiles were all up on you. I was most scared of the gas." The examiner noted that the Veteran had over 30 prior hospital admissions beginning in the 1990's. The majority of the hospitalizations had a discharge diagnosis of psychosis and alcohol abuse, and sometimes one of those diagnoses and not the other. Two hospitalizations also included a "rule out PTSD" diagnosis. The examiner found no evidence that the Veteran received any type of psychiatric treatment while he was in the military. He reported that he thought about his military experiences "every now and then." He reported having dreams regularly but these did not appear to have a military theme. The examiner was unable to elicit clear symptoms of avoidance. He did endorse some hypervigilance. The Veteran reported that his first psychotic episode was in 1998 after drinking and smoking marijuana. He reported experiencing another psychotic episode in 2001 when he was getting paranoid. At the time of the interview, the Veteran denied such full blown symptoms. It was noted that the Veteran had significant tangentiality of thought and showed frequent derailment when discussing his history and his symptoms. Overall, the Veteran demonstrated significant impairment in communication and thought processes. He had significant impairments of both judgment and insight given his long history of polysubstance abuse and recurrent legal problems. He reported being compliant with his medication and that it helped him "mellow out" and helped him with sleep. He reported that he typically got six hours of sleep, or more if he did not have a dream. He denied any episodes of irritability since becoming sober 16 months ago. He described his mood as slightly anxious and had constricted affect throughout the interview. He denied any thought of suicide or homicide. The examiner diagnosed residual schizophrenia. The examiner noted that the Veteran did not display characteristic symptoms of PTSD, particularly in terms of avoidant symptoms. He had some symptoms that were similar to arousal symptoms, but these were better accounted for by schizophrenia. He appeared to have psychotic symptoms since the mid 1990's, but the examiner was unable to find any indication that he was treated for this symptoms while he was in the military. In an April 2012 addendum, an examiner stated that the Veteran's schizophrenia was less likely than not due to service, reasoning that there was no indication that the Veteran had any type of psychiatric treatment in the military and his first psychotic episode appeared to be in 1998, which was six years after discharge. Various treatment records from early 2012 indicate that the Veteran reported he had been sober for many months. In April 2012 he reported that he was "doing great." At that time there were no psychotic symptoms, no paranoia, and the Veteran had a stable job (through vocational rehabilitation) and living arrangements. In August 2012 the Veteran submitted a periodical article suggesting that schizophrenia may be caused or aggravated by stress. The Veteran was reexamined again by VA in October 2012 and May 2013. In the October 2012 report, the examiner opined that the Veteran did not have PTSD and did not have any other mental disorder. The examiner noted that the Veteran was last seen in April 2012 and reported that he was "doing great." The mental health provider noted that the Veteran had no mental health symptoms and was responding well to medications. At the examination, the Veteran reported that he had some anxiety that started a month ago and this had been off and on for many years. He reported some occasions when he would hear people talking in his head. He denied nightmares or avoidance symptoms of PTSD. He endorsed some arousal symptoms more attributable to his anxiety. The Veteran reported that he had been substance free for two years. He attended a substance abuse program in 2010 and was diagnosed with schizophrenia, PTSD, cannabis and cocaine abuse, and alcohol dependence. The Veteran reported that in the Persian Gulf he was exposed to mortar rounds and a plane crash. Therefore, he met criterion A for PTSD. However, he did not meet any of the other criteria. The examiner opined that based on the interview with the Veteran and review of records, the Veteran did not meet the criteria for PTSD or for any other mental illness. Therefore, it was less likely than not that the Veteran had PTSD or any mental illness related to a fear of hostile military or terrorist activity or any military experience. In March 2013 the same examiner provided a more comprehensive report detailing the reasons for his opinion that the Veteran did not have a mental disorder that was related to his military service. The examiner conducted an extensive review of the Veteran's treatment history, and the various diagnoses that were assigned over time. He observed that while the Veteran had a long history of mental health treatment, and certainly experienced stressors in his life, there was no compelling evidence in his records to indicate why he was given specific diagnoses or how they were related to his time in the military. The consistent theme found by the examiner was that the Veteran goes through periods of intoxication and sobriety and that his behavior tends to be more disruptive when he is intoxicated. The examiner listed examples of this from the Veteran's treatment records. With respect to the diagnosis of depression and suicidal ideation in August 1993, there was a substance abuse treatment program note from the day after the Veteran's admission indicating that he had an alcohol problem and had participated in four prior detoxification programs. The diagnosis of alcohol abuse was made and the note indicated that the Veteran was intoxicated at the time he was brought to the hospital. The Veteran had four subsequent admissions for substance abuse treatment in 1994 and the diagnosis assigned was either substance abuse or dependence. The Veteran was seen at a VA Medical Center in an outpatient substance abuse program in 1995 and 1996 and a review of the notes showed that the Veteran reported periods of sobriety and his behavior tended to escalate when he relapsed. The examiner opined that during this period, the Veteran was being treated for a substance abuse disorder, and when he was sober treatment notes indicated that he was asymptomatic. The examiner noted that the Veteran followed this pattern all through his extensive treatment history. Therefore, it was less likely than not that the Veteran had depression related to his military service. With respect to the diagnosis of schizophrenia in June 2011, the examiner noted that the Veteran was diagnosed with schizophrenia at that particular VA Medical Center in March 2010 after the Veteran was seen for a psychosocial assessment leading up to admittance for substance abuse inpatient treatment. The examiner noted the description of the Veteran's presentation at that time, and that at discharge he was diagnosed with schizophrenia, alcohol dependence, and cocaine and cannabis abuse. During that hospitalization, the Veteran reported that he had flashbacks and nightmares from the Gulf War in which he got shot at and witnessed people dying. He reported that he also had schizophrenia. The examiner explained that the treatment notes do not show a clear pattern of schizophrenia. Providers noted that he was either asymptomatic or overall functioning well when he was sober. The examiner could not determine why the Veteran was given the diagnosis of schizophrenia. In addition, the PTSD diagnosis was not supported by the description of the Veteran in the treatment notes. Furthermore, the Veteran did not provide enough symptoms to warrant a PTSD diagnosis in the October 2012 examination. Therefore, it was less likely than not that the Veteran had schizophrenia related to his military service. With respect to a June 2009 anxiety disorder diagnosis, treatment notes associated with that diagnosis stated that the Veteran's sleeping was better, and his appetite and energy had decreased. He denied suicidal or homicidal thoughts or hallucinations. There was no indication why the Veteran was given this diagnosis and it was less likely than not that he had an anxiety disorder related to the military. The examiner also noted that the Veteran was diagnosed with an adjustment disorder in May 2011. Review of the treatment records indicated that the Veteran was seen at the drop in center for an adjustment to his living situation and being homeless. No significant mental health problems were noted. Thus, it was less likely than not that the Veteran had an adjustment disorder related to military service. With respect to the diagnosis of PTSD in the treatment records, those records do not describe PTSD symptoms and the Veteran appeared to function well while sober. Therefore, it was less likely than not that the Veteran had PTSD secondary to military service. In summary, the examiner provided that the treatment notes either do not adequately delineate the bases on which the diagnoses were based or provide a diagnosis which is unrelated to the Veteran's military experiences. In late 2012 the Veteran reported symptoms again when he was off medications; they got better when he restarted the medications. However, subsequent treatment records also indicate that the Veteran had relapsed into substance abuse in late 2012 or early 2013. His symptoms, including paranoia, returned and became more prominent at that time. Analysis The evidence does not show that it is at least as likely as not that the Veteran has PTSD, schizophrenia, or any other mental health diagnosis that is related to his military service. At the outset, the Board notes that the analysis below focuses on the most salient and relevant evidence. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board also notes that the Veteran served in the Persian Gulf theater of operations and has a Combat Action Ribbon. The Board has considered 38 U.S.C.A.§ 1154(b). The Board does not doubt the Veteran's reports of exposure to stressful situations such as fear of chemical weapons while in theater. However, exposure to wartime stressors alone does not establish entitlement to service connection for PTSD or any other mental disorder. There are medical opinions of record which are favorable and not favorable to the claims on appeal. With regard to medical opinions, the credibility and weight to be attacked to a medical opinion are within the Board's province as finder of fact. Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). Greater weight may be placed on one opinion over another depending on factors such as the reasoning employed and whether the examiner was informed of the relevant facts. Nieves Rodriguez v. Peake, 22 Vet. App. 295 (2008). Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444 (2000). With regards to the claim for service connection for PTSD, the Veteran was evaluated in connection with this claim on numerous occasions. At only one evaluation was the Veteran diagnosed with PTSD, which was in September 2003 by Dr. L.H.. Dr. L. H. had specifically determined that the Veteran did not have PTSD in her earlier 1998 examination. She gave no explanation for the change in diagnosis, and did not mention her earlier report at all in the September 2003 report. Moreover, her diagnosis was based on the Veteran's report of learning another soldier committed suicide while he was in Southwest Asia. The Veteran's report of this incident is not credible given that he did not mention it at any of his other VA examinations or at any time during his extensive treatment history. The Veteran was evaluated again that same month by a different examiner and that examiner diagnosed psychotic disorder NOS, substance abuse disorders, and probable personality disorder NOS. He specifically opined that the Veteran did not have PTSD. Both of these reports were reviewed by another examiner in January 2004, after a recent hospitalization. That examiner opined that the Veteran did not have PTSD and did not have any other mental health problem that was related to his military service. He was not diagnosed with PTSD in the evaluations that took place in October 1996, July 1998, the second evaluation in September 2003, January 2004, June 2011, and October 2012/May 2013. Thus the Veteran was comprehensively evaluated for his claimed PTSD symptoms on seven occasions, and six times examiners determined that the Veteran did not have PTSD. PTSD was apparently added to the Veteran's "problem list" in August 2010. It is unclear why this diagnosis was made or what, if any, evaluation resulted in this diagnosis. Prior to this, as late as a hospitalization in August 2009, the Veteran was diagnosed with various substance abuse disorders, schizoaffective disorder, anxiety disorder NOS, and personality disorder NOS, and not PTSD. It is notable that in September 2003 the Veteran's psychiatrist specifically wrote that the Veteran did not have PTSD. While the Veteran was also diagnosed with PTSD amongst other disorders by a medical student in November 1997, as noted by subsequent reviewers this individual was not a psychologist or psychiatrist and was not fully trained to diagnose mental disorders. Diagnoses from other providers at the VA Medical Center around this time did not support a PTSD diagnoses; providers diagnosed substance abuse disorders and, at times, psychosis. In sum, the overwhelming majority of the evidence weighs strongly against any finding that the Veteran has PTSD related to his military service. He has been comprehensively evaluated on numerous occasions for treatment purposes and for compensation purposes, and the great majority of the time a diagnosis other than PTSD was made, with the most common diagnoses being substance abuse disorders, personality disorder, and schizophrenia/schizoaffective disorder. The one time the Veteran was diagnosed with PTSD by an examiner, her diagnosis was based on a stressor that the Veteran did not report at any other time and was in direct contradiction to an earlier evaluation she had done of the Veteran. The Veteran was hospitalized just a few months prior to this examination and was diagnosed with schizoaffective disorder and polysubstance dependence but not PTSD. Moreover, the Veteran was evaluated later the same month by another provider and found not to have PTSD, and her report was also considered by a third provider in January 2004 and the examiner opined that the Veteran did not have PTSD, specifically noting the contradiction in the two reports prepared by Dr. L.H. While PTSD is noted in the Veteran's current problem list in his VA treatment records, this is accorded little weight in that there is no explanation of how this diagnosis was arrived at or what factors were considered to make this diagnosis. Its probative value is outweighed by the numerous examination reports and hospital reports which indicate that PTSD was not diagnosed (although the possibility was at infrequent times briefly entertained). Similarly, the opinion of the medical student is of limited probative value, because the record does not provide any rationale for how the medical student arrived at any of the diagnoses. It is outweighed by the findings of the psychologists and psychiatrists who evaluated the Veteran at six of his VA examinations and also during numerous hospitalizations, which did not diagnose PTSD. At a hospitalization in July 1997 the Veteran was diagnosed with "rule out PTSD." This is not the same as a diagnosis of PTSD and during the overwhelming majority of his hospital admissions, the Veteran was not diagnosed with PTSD. The Veteran has also been diagnosed with mental disorders other than PTSD, most often schizophrenia or schizoaffective disorder, as well as more occasional diagnoses of disorders such as depression, anxiety disorder NOS, panic attacks, and adjustment disorder. There is little support for the diagnoses other than schizophrenia and schizoaffective disorder (depression, anxiety disorder, panic attacks, adjustment disorder) as they are infrequently and intermittently diagnosed although the Veteran was examined seven times in connection with this claim and examined for treatment purposes on an inpatient and outpatient basis numerous times. Additionally, none of these diagnoses were ever related to the Veteran's service by any health care provider. It is notable that these diagnoses were of record at the time of the October 2012/May 2013 examination and the examiner specifically found the Veteran did not have any of these disorders, providing a well-reasoned rationale for why the Veteran did not have depression, anxiety disorder, or an adjustment disorder that was related to military service. While the evidence is less clear with respect to whether the Veteran has a psychosis, either schizophrenia or schizoaffective disorder, the Board finds that the opinions of the October 2012/May 2013 examiner and the January 2004 examiner, to the effect that the symptoms with which the Veteran presented were better explained by his substance abuse, to be the most probative evidence. Both of these opinions were based on a comprehensive review of the claims file, including the other examinations of record at the time as well as the Veteran's extensive substance abuse and psychiatric treatment history. The examiner who prepared the January 2004 report noted that the Veteran often presented to the hospital under the influence of alcohol or drugs, and that this complicated diagnostic impressions and led some providers to diagnose schizophrenia. The examiner noted that at the hospitalizations that occurred shortly prior to his report, the Veteran was diagnosed only with substance abuse disorders and a personality disorder and after a brief hospitalization in May 2003 providers felt that what had previously been diagnosed as schizoaffective disorder was alcohol induced. The examiner who prepared the October 2012 and May 2013 reports noted that when the Veteran was last seen for psychiatric reasons he reported that he was "doing great" and he was not felt to have any mental health symptoms at that time. The examiner noted that the Veteran had a pattern of presenting with much more prominent symptoms when he was under the influence of alcohol or drugs. He was asymptomatic or otherwise functioning well when he was sober. The treatment records did not show a clear pattern of schizophrenia. This examiner's opinion is corroborated by the most recent VA treatment records. During a period of sobriety, the Veteran reported that he was doing well, and he was able to successfully participate in a vocational rehabilitation program and work. When he relapsed around early 2013, paranoia and suspiciousness again became prominent symptoms. The October 2012/May 2013 examiner's review most fully explains all of the evidence and prior diagnoses, and additionally it is consistent with the January 2004 examination. Moreover, regardless of whether a psychosis is diagnosed, there is no opinion relating any psychosis to the Veteran's military service. Continuity of symptoms since service is not shown, in that as the January 2004 and October 2012/ May 2013 examiners explained, the Veteran's symptoms are better accounted for by his substance abuse problem. As discussed above, considering the relative merits and the analytical findings of the opinions, the Board places the greatest weight on the findings for the examiner who prepared the October 2012 and May 2013 reports. As previously discussed, the only favorable opinion which related a mental disorder to the Veteran's military service was based on inaccurate facts and directly contradicted an earlier report by the same examiner with no rationale given for the change in diagnosis. Moreover, the opinions which diagnosed various psychoses, albeit unrelated to service, did not account for the evidence that the Veteran's symptoms were closely associated with his alcohol abuse, waxing and waning with the Veteran's periods of alcohol use, with symptoms acutely exacerbated when the Veteran was intoxicated and largely remitting when he was sober. The examiner's reports from October 2012 and May 2012 fully considered the nature of the Veteran's symptoms and history prior to arriving at a well-reasoned opinion. Under certain circumstances, a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a general matter, lay witnesses are competent to testify to their observations and opine on questions of diagnosis and etiology in some circumstances. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (lay witnesses are competent to testify as to their observations, but this testimony must be weighed against the other evidence of record); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptoms, when the determination is not medical in nature and is capable of lay observation). See also Davison v. Shinseki, 581F.3d 1313 (Fed. Cir. 2009) (categorical statement that a medical opinion was required to establish nexus and that a layperson was not competent to provide testimony as to nexus conflicts with Jandreau, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology). The Board considered the Veteran's lay statements and acknowledges that he is competent to give evidence about what he experienced or observed. The Veteran's report of experiencing symptoms such as paranoia, depressed mood, and anxiety are credible and well supported by the record, although the Board notes that they are primarily documented during periods when the Veteran was intoxicated. However, the Veteran's statements about the etiology of his symptoms are outweighed by those of the multiple examiners and treating mental health professionals who determined that he did not have PTSD, including the examiners who prepared the January 2004 and October 2012 and May 2013 reports which attributed the Veteran's symptoms to substance abuse rather than another mental disorder. As previously discussed, the latter opinions, which reflect the examiners' specialized knowledge, expertise, and experience in diagnosing and treating mental disorders as well as consideration of all relevant lay and medical evidence of record, are highly probative. The diagnosis of a mental disorder, as well as a determination of its etiology, are complex medical matters beyond the ken of a layperson. Jandraeu v. Nicholson, 492 F.3d 1372 (2007). Whether the Veteran has a mental disorder other than substance abuse, and the nature and causation of any such disorder, are questions that require specialized training and are therefore not susceptible to lay opinion. In this regard, a medical professional has greater skill. As previously discussed, the Board finds the opinion of the examiner who prepared the October 2012 and May 2013 report to be the most probative among all the medical and lay evidence in this case. While service connection for psychosis may also be granted if it is present to compensable degree within one year of service, the Board has found that the weight of the evidence shows that the Veteran does not have schizophrenia, schizoaffective disorder, or any other psychosis. The Board also notes that psychosis was first documented in 1994, which is more than one year after service. While psychoses such as schizophrenia and schizoaffective disorder are among the chronic diseases under 38 U.S.C.A. § 1101 and 38 C.F.R. § 3.309(a), see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Veteran's assertion of continuity of symptoms since service is outweighed by the medical documentation from shortly after service that showed no diagnosis of any psychosis until more than two years after service, despite observation by medical professionals shortly after service during several hospitalizations for substance abuse related problems. Furthermore, as explained above the Board finds that the weight of the evidence shows that the Veteran's symptoms are not related to a psychosis but rather to substance abuse and that the Veteran does not currently have a psychosis, nor did he have a psychosis at any time pertinent to this appeal. With respect to the Veteran's personality disorder, which has intermittently been diagnosed, to the extent that this disorder exists it is considered a developmental defect and is not subject to service connection nor does the evidence show that a disability from a mental disorder was superimposed upon the personality disorder. 38 C.F.R. §§ 4.9, 4.12. As for the Veteran's alcohol and cannabis abuse, service connection for primary drug or alcohol abuse is prohibited by law. 38 U.S.C.A. § 105, 38 C.F.R. § 3.301. While service connection for alcohol abuse may be granted on a secondary basis, Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001) here there is no evidence that the Veteran's substance abuse problems are related to a service connected disability. The Veteran is not service connected for any disability. The benefit of the doubt was considered, but the weight of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Accordingly, the appeal is denied. ORDER Service connection for an acquired psychiatric disorder, including PTSD and schizophrenia, is denied. ____________________________________________ M. Mac Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs