Citation Nr: 1331758 Decision Date: 10/02/13 Archive Date: 10/07/13 DOCKET NO. 09-13 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), schizophrenia, and bipolar disorder. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from October 1974 to September 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada, in which the RO, in pertinent part, denied service connection for PTSD. In August 2012, the Board discussed that, while the claim had been certified as a claim of entitlement to service connection for PTSD, the Board had recharacterized the issue on appeal to reflect the Veteran's contentions that he also had bipolar disorder and schizophrenia. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. After completing the additional development, the AMC continued to deny the claim (as reflected in an April 2013 supplemental statement of the case (SSOC)), and returned this matter to the Board. The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the AMC in the most recent supplemental statement of the case (SSOC). Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. There is credible evidence of record that corroborates the Veteran's report of the reported stressor of in-service personal assault. 3. The evidence is at least evenly balanced as to whether or not the Veteran has current PTSD associated with the in-service personal assault. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a psychiatric disorder, specifically, PTSD, are met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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, 3.326(a) (2013). Given the favorable disposition of the claim for service connection for PTSD, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. The Board notes, however, that the RO sent the Veteran VCAA notice letters in July 2007 and March 2008 which provided notice of what evidence was required to substantiate his claim for service connection for PTSD, and of his and VA's respective duties for obtaining evidence in correspondence. After issuance of these letters, the November 2008 rating decision was issued. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in the July 2007 and March 2008 letters. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file and Virtual VA e-folder shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records, service personnel records, and VA and private treatment records have been obtained and associated with his claims file/e-folder. The Veteran was also provided with VA examinations in February 2011 and September 2012 and an additional medical opinion was obtained in April 2013. The case was remanded in August 2012 to obtain additional VA treatment records, to give the Veteran the opportunity to file authorization forms to allow for the release of private treatment records from the "Friendship Center for Socialization", to obtain records from the Social Security Administration (SSA), and to afford the Veteran a VA examination. Additional VA treatment records as identified in the August 2012 remand were associated with the Virtual VA e-folder in September 2012. Also in September 2012, the AMC asked the Veteran to complete and return an enclosed VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), to enable it to obtain treatment records from the Friendship Center for Socialization. The Veteran did not subsequently provide such a release. VA is only obligated to obtain records that are adequately identified and for which necessary releases have been received. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As the Veteran has not provided a release form for these private treatment records; it is not possible for VA to obtain them. The AMC requested the Veteran's records from SSA, but SSA responded in September 2012 that the records had been destroyed. The Veteran was advised of the unavailability of his SSA records via letter in April 2013. The Veteran was afforded a VA examination in September 2012. This examination report is responsive to the August 2012 remand directives and the VA examination reports and opinions of record are adequate to evaluate the claim on appeal. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007). There was substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis The Veteran asserts that he has PTSD related to an in-service personal assault, specifically, being hit in the head by a crowbar. Service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder; a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s); and credible supporting evidence that the claimed in-service stressor(s) actually occurred. 38 C.F.R. § 3.304(f). The present case falls within the category of situations, to include allegations of personal assault, in which it is not unusual for there to be an absence of service records documenting the events of which the veteran complains. See, e.g., Patton v. West, 12 Vet. App. 272, 281 (1999). The pertinent regulation, 38 C.F.R. § 3.304(f), reflects a recognition that service records may not contain evidence of personal assault, and that alternative sources, including testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, may provide credible evidence of an in-service stressor premised on personal assault. See YR v. West, 11 Vet. App. 393, 399 (1998). See also VA Adjudication Manual, M21-1MR, Part IV, Subpart ii, Chapter 1, Section D, Topic 17, Developing Claims for Service Connection for PTSD Based on Personal Trauma (Sept. 8, 2009). Specifically, under 38 C.F.R. § 3.304(f)(4), if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases, and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. See 38 C.F.R. § 3.304(f)(4). Effective July 13, 2010, VA amended its regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard to establishing the required in-service stressor. Specifically, 38 C.F.R. § 3.304 was amended to include a paragraph which, in pertinent part, states that, 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. See 38 C.F.R. § 3.304(f)(3). While the amended regulation applies to all claims seeking service connection for PTSD that were appealed to the Board by July 13, 2010 but not yet decided by the Board as of that date, the Board finds the amended regulation is not for application in this case because the Veteran's reported stressor does not involve fear of hostile military or terrorist activity, as contemplated by the regulation. Instead, as discussed, the Veteran claims service connection for PTSD related to in-service personal assault. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Considering the pertinent evidence of record in light of the above-noted legal authority, and resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for PTSD is warranted. Service treatment records are negative for psychiatric complaints or findings. In his October 1974 Report of Medical History at enlistment, the Veteran denied depression or excessive worry and nervous trouble of any kind. On examination, clinical evaluation of the psychiatric system was normal. In January 1975, the Veteran reported that he had been mugged and had been hit in the back of the head with a metal object. On examination, the Veteran had a laceration on the back of his head, which was closed with six sutures. Service personnel records reflect that, in a form completed by the Veteran in September 1974, he responded positively to the question of whether he had ever been arrested, charged, or held by a law enforcement authority as well as whether he had ever been convicted of any offence. He elaborated in the remarks section, indicating that in October 1973 he was charged with going the wrong way on a ramp and in February 1974 he was fined for running a red light. He denied ever having been under the care of a psychiatrist or psychologist, ever having been a patient in a mental health institution, ever having taken any narcotic substance, sedative, stimulant tranquilizer drugs, or alcoholic beverages to excess, ever sniffing glue, or ever having been involved in the use, purchase, possession, or sale of drugs, including marijuana. In July 1975, the Veteran received nonjudicial punishment for unauthorized absence. In August 1975, the Veteran received nonjudicial punishment for unauthorized absence and breaking restriction. Later that month, he received nonjudicial punishment for unauthorized absence and disobeying a lawful order from a commissioned officer. His Form DD 214 reflects four periods of unauthorized absence between March and August 1975. In September 1975, the Veteran's commanding officer recommended discharge due to frequent involvement of a discreditable nature with military authorities and summarized his nonjudicial punishments. Post-service, in December 1994, the Veteran was evaluated by a private psychologist, Dr. P.M.H., regarding his competency to stand trial for criminal charges. The psychologist commented that it required considerable questioning to obtain a coherent description of the Veteran's recent as well as past history. The Veteran reported that he quit school when he was arrested for auto theft, but earned a G.E.D. in jail in 1976. In addition to his auto theft as a juvenile, the Veteran reported being arrested for grand theft of a motor home in 1982. The psychologist interviewed the Veteran's sister, who described a family history of mental illness and reported that the Veteran had periodic depression from childhood. The Axis I diagnoses following examination and psychological testing were psychoactive substance abuse, not otherwise specified (history of polysubstance and alcohol abuse) and atypical psychosis, rule out organic mental disorder. The psychologist noted that the Veteran appeared to be confused and he had great difficulty providing coherent responses and it was nearly impossible to obtain a coherent history. It was recommended that the Veteran be placed in a secure psychiatric hospital facility. In January 1995, the Veteran was admitted to a state hospital as incompetent to stand trial following criminal charges. The psychiatrist noted that the Veteran gave contradictory information. The psychiatrist stated that criminal arrest history was included in the legal section of his chart, but reports indicated that he had been arrested for auto theft as a juvenile and was arrested for grand theft of a motor home in 1982. The Veteran reported that he was first arrested at age 15 for running away from home, for which he "spent a few days in juvenile hall," but denied any other teenage arrests. The Veteran was a reluctant historian regarding his substance abuse history, indicating that he began smoking marijuana and drinking beers with friends at age 14. He also reported sniffing gasoline as a teenager. He stated that alcohol had been his main problem, and alluded to using methamphetamines in the early 1980s. The Veteran reported that he was suspended four or five times in school for smoking and ditching school. In discussing his history, the Veteran reported that he had been arrested at 15 for running away, and then again ran away, during which time he was sexually molested. He denied being physically abused as a child. He denied a history of head trauma. The diagnoses were psychotic disorder not otherwise specified, organic mental disorder not otherwise specified, (provisional), and polysubstance dependence. In June 1995, the Veteran was again evaluated by Dr. P.M.H. In summarizing records he had reviewed, the psychologist commented that, on discharge from the state hospital in April 1995, the Veteran was considered competent to stand trial and was given diagnoses of schizophrenia, undifferentiated type, and substance dependence. The psychologist commented that an August 1993 record from another facility revealed diagnoses of major depression and alcohol dependence. The Veteran reported that he had been hearing vague voices and having confused thoughts since approximately August 1993. The Axis I diagnoses following examination and psychological testing were schizophrenia, paranoid type, and polysubstance dependence (marijuana, alcohol). The psychologist commented that the Veteran began evidencing a deterioration of his behavior approximately seven to eight years earlier. Mental health treatment records from February 1996 to April 1997 include Axis I diagnoses of rule out psychotic disorder; rule out PTSD; rule out schizophrenia, residual type; impulse control disorder, not otherwise specified; polysubstance dependence; and amphetamine dependence, in remission. In describing his health history during treatment in December 1996, the Veteran reported that he had been hit in the back of the head with a crowbar and knocked unconscious for a few seconds. VA treatment records reflect a positive PTSD screen in May 2007. On mental health intake assessment in June 2007, the Veteran reported that needed "a diagnosis so I can get some money." The social worker stated that she, "would not just give him a PTSD dx [diagnosis] without a more thorough discussion of his PTSD sx [symptoms]." The Veteran was evasive when answering questions and the social worker described him as an inaccurate historian, for example, he denied having alcohol or legal problems. The Veteran reported participating in a PTSD program while in prison, and stated that the doctor there had also diagnosed him with bipolar disorder and schizophrenia. He denied problems during childhood and denied childhood physical, emotional, or sexual abuse. He reported that, at age 14, his father put him in juvenile hall for "having too much sex with females." The Axis I diagnosis following mental status examination was alcohol abuse, continuous, by history. The Veteran reported that he had PTSD "because others do" but the social worker noted that he was unable to state any symptoms of PTSD other than nightmares and was vague when asked about experiences in the military or traumatic stressors. She commented that the Veteran's insight and judgment appeared to be poor and there appeared to be secondary gain issues motivating him to seek mental health treatment. A January 2008 VA outreach note reflects that the Veteran reported a history of alcohol use and hepatitis C, but denied other medical, mental health, or drug problems. PTSD screen on that date was negative. The Veteran denied mental health history during treatment in August 2009. The Axis I diagnosis was homelessness. PTSD and depression screens on that date were negative. During treatment in August 2010, the Veteran denied any mental health history. The Axis I diagnosis on that date was alcohol abuse, not otherwise specified. Treatment records dated in December 2010, February 2011, and March 2011 reflect diagnoses of adjustment disorder, not otherwise specified. PTSD and depression screens were negative in August 2012. The Veteran was afforded a VA general medical examination in January 2011, at which time psychiatric review of systems was negative. The Veteran denied a history of depression, panic attacks, substance abuse, memory problems, anxiety, confusion, sleep impairment, and other symptoms. Psychiatric examination was normal. The Veteran was afforded a VA mental disorders examination in February 2011, apparently in conjunction with an August 2010 claim for nonservice-connected pension. In describing his pre-military history, the Veteran denied any problematic effects associated with alcohol use and denied other substance use. He reported legal problems prior to service, specifically, being arrested for joyriding. However, the examiner noted that, during the June 2007 mental health intake assessment, the Veteran had reported that his father put him juvenile hall at age 14 for "having too much sex with females." In describing his military history, the Veteran reported three write-ups, two for unauthorized absences and one for disrespecting an officer. He denied in-service alcohol abuse and denied problematic effects from other substance use or abuse. In describing his post-military legal history, the Veteran reported that he had a felony conviction and had had many arrests. In describing post-military issues associated with alcohol use, the Veteran reported that he had a history of two DUI (driving under the influence) charges and his marriage had broken up over his drinking habits. In regard to other substance use, the Veteran reported being involved in methamphetamines, cocaine, and other drug use for many years. In regard to his medical history, the Veteran reported being hit in the head with a crowbar during service. In discussing his history of mental health treatment, the Veteran reported treatment from 1993 to 2002 and stated that he sought treatment for depression following being charged with a sexual offense because it was a very stressful time and his mother died around that time as well. The examiner commented, however, that later in the interview it sounded like this mental health treatment may have been associated with the terms of his parole. On examination, psychomotor activity, speech, thought process, and thought content were unremarkable. Mood was good, affect was appropriate and orientation and attention were intact. The Veteran did describe sleep impairment, reporting that he had not slept well since service. The examiner commented that the Veteran appeared to be forthcoming, but the reported timeline and details of events was conflicting and incomplete at times. For example, he first reported that he spent 17 months in prison for a sexual offense in the early 1990s, but he was actually in prison for 17 months at that time and then for another 17 months between 2007 and 2009 for failure to register. Later he reported that he had been in prison almost continuously between 1993 and 2002 for failure to register. The examiner stated that the Veteran's extensive history of alcohol and drug abuse coupled with his current medical conditions might be affecting his ability to accurately report the timeline of events and his verbal memory. Psychological testing was not completed. The February 2011 VA examiner's Axis I diagnoses were history of alcohol abuse; history of amphetamine abuse; and rule out cognitive disorder, not otherwise specified. She commented that the Veteran did not meet the criteria for an Axis I diagnosis. She stated that he had a history of significant alcohol and drug abuse, but did not meet the criteria for either of these diagnoses at the time of examination. She added that, given the vague and inconsistent timeline of events reported during the examination, coupled with his uncontrolled diabetes, she had added a diagnosis of rule out cognitive disorder, not otherwise specified, as these inconsistencies might be at least partly related to executive functioning and/or verbal memory impairments. Pursuant to the Board's August 2012 remand, the Veteran was afforded a VA PTSD examination in September 2012. The examiner indicated that, based on the current examination and clinical findings, the Veteran had a diagnosis of PTSD which conformed to the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The Axis I diagnoses were PTSD, chronic, moderate, and alcohol dependency, full sustained remission (by self report). The examiner commented that the Veteran did not have more than one mental disorder diagnosed. He indicated that it was not possible to differentiate what symptoms were attributable to each diagnosis, reporting that, by the Veteran's report, his alcohol dependency was in full sustained remission and, even if this was not true (which he described as not unlikely), the symptoms described were due to PTSD and not to alcohol dependency. The examiner noted that the Veteran's reported trauma involved being hit in the head with a crowbar. The Veteran reported that he was unconscious for 30 minutes. Prior to reporting his clinical findings, the VA examiner indicated that he had reviewed the claims file and had also thoroughly reviewed the medical records in the Computerized Patient Record System (CPRS), conducted a full clinical interview with mental status examination, and had administered the PTSD Checklist, Military Version (PCL-M). In discussing his history, the Veteran denied emotional, physical, or sexual abuse in his family of origin. He reported that he dropped out of school in the 10th grade and denied any significant disciplinary issues during school. He denied any issues with depression or anxiety prior to his military service, and stated that he obtained mental health counseling for depression, anxiety, and drug use in 1980 for about five years. The Veteran denied any legal problems either prior to or following his military service but reported that, following his in-service personal assault, he received multiple disciplinary actions. However, the examiner noted that the June 2007 mental health intake assessment indicated that, at that time, the Veteran had reported three DUIs and five years in prison for grand theft auto and a sex offense. In regard to substance abuse, the Veteran denied alcohol use prior to enlistment, but he reported social use of marijuana. He stated that, during service, his drinking of alcohol increased dramatically; although he denied any drug use during service. He reported that, after service, his heavy drinking continued, along with regular use of marijuana and methamphetamine. The Veteran stated that he stopped all use of alcohol and drugs in 1990; however, the examiner observed that, during VA treatment in July 2007 he stated that he drank "4-5 drinks 2-3 nights per week." In describing his in-service stressor, the Veteran reported that, following basic training, but before leaving San Diego, he was "jumped on shore by 2 'large black men' who held him down and 'hit me on the head with a crowbar.'" The Veteran reported that he feared for his life. The examiner opined that this stressor met Criterion A, as it was adequate to support the diagnosis of PTSD. The examiner checked the various criteria used for establishing the diagnosis of PTSD, from DSM-IV. The examiner indicated that the Veteran satisfied each criterion, A through F, and indicated that the PTSD diagnosis was related to the Veteran's reported stressor. The examiner commented that the Veteran met all diagnostic criteria for PTSD, caused by the traumatic event which occurred while enlisted. He observed that the Veteran's service treatment records documented treatment for a head injury in January 1975, consistent with the Veteran's report. He opined that subsequent disciplinary actions were consistent with markers related to personal assault and PTSD as a result of that assault. The examiner stated that he was aware that the Veteran had denied PTSD symptoms according to a January 2008 VA treatment record, and that multiple pieces of information given by the Veteran were at odds with information from previous reports, but stated there was no doubt that the Veteran was a poor historian with a lengthy history of alcohol and drug-related problems. Nevertheless, the examiner found that the Veteran's report of assault was credible based on his service treatment records and markers (disciplinary actions which did not happen prior to the assault) for an emotional reaction to this assault were present. The examiner concluded by stating that, therefore, it was his opinion that the Veteran did have PTSD more likely than not caused by the described personal assault. In January 2013, the AMC requested an additional medical opinion. In April 2013, a VA physician reviewed the claims file and Compensation and Pension Record Interchange (CAPRI) records. She included in the "Background" section of her report the multiaxial diagnosis from the February 2011 VA examination report, as well as that VA examiner's comments. The January 2013 examiner opined that it was less likely than not that the Veteran's claimed PTSD incurred in, was caused by, or was aggravated by his time in military service. She noted that the Veteran was homeless with a past history of incarceration as a sex offender and alcohol and drug abuse. In providing a rationale for her opinion, she stated that the 2007 and 2008 mental health examinations found that it was less likely than not that the Veteran's claimed PTSD was caused or aggravated by his time in service. She stated that she was in full agreement with these examiners. She added that, although the Veteran sustained a laceration of the head in 1975, the wound was sutured closed and healed without complications and the medical note did not indicate any signs or symptomatology of head or neck problems. The examiner opined that the 1975 laceration was a simple, non-complicated wound and, thus, "LESS LIKELY THAN NOT the precursor to, proximately due to or aggravated his claimed PTSD." Therefore, she stated, she was in full disagreement with the September 2012 VA examiner. The April 2013 VA examiner went on to comment that the Veteran had a past medical history of alcohol and drug abuse, and reported that there was medically based scientific evidence supporting that clinical symptoms of "hearing voices" and hallucinations are associated with a history of alcoholism (providing reference to a medical text indicating that alcoholism and substance abuse should also be considered as a possible etiology of psychosis). Based on this, she opined that the 1994 mental health assessment was less likely than not a true analysis of the Veteran's mental health condition at the time of his pending incarceration. Finally, she concluded by noting that the Veteran "was on active duty for less than one year and underwent court martial over the last 5 months (January to May 1975)." She indicated that the Veteran was not exposed to a traumatic event in which the person's response involved intense fear, hopelessness, or horror and did not experience, witness or was confronted with an even that involved actual or threatened death or serious injury or a threat to the physical integrity of others. Therefore, she concluded, it was less likely than not that the Veteran's claimed PTSD incurred during or was caused or aggravated by his time on active duty. Here, the January 1975 service treatment record corroborates the Veteran's report of his in-service personal assault stressor. The Board acknowledges that the Veteran denied a history of head trauma during his January 1995 hospitalization; however, the contemporaneous service treatment record is more probative than the history given in 1995, 20 years after the reported personal assault. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). The Board also recognizes that the Veteran has made some inconsistent statements regarding the nature of his head injury, for example, reporting in December 1996 that he had been hit in the back of the head with a crowbar and knocked unconscious for a few seconds, but reporting during the September 2012 VA examination that he was unconscious for 30 minutes following this assault. The Board observes that numerous medical records indicate that the Veteran is an unreliable historian. Nevertheless, the fact remains that the in-service personal assault is corroborated by the contemporaneous medical records. The remaining question is whether the Veteran has a current psychiatric disorder, to include PTSD, related to this in-service stressor. There is conflicting medical evidence on this point. In the case of conflicting medical evidence, it is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In favor of the claim for service connection is the opinion of the September 2012 VA examiner, who found that the Veteran had a diagnosis of PTSD related to the in-service personal assault. The Board recognizes that the September 2012 opinion was based on a finding that the Veteran had in-service disciplinary actions which did not happen prior to the assault that were consistent with markers related to personal assault and PTSD as a result of that assault. The record includes numerous inconsistent reports from the Veteran regarding his history, and there is some indication that he had disciplinary/legal problems prior to the in-service personal assault. In this regard, at entry into service the Veteran reported that the only legal charges brought against him were for going the wrong way on a ramp and running a red light. He has since reported that he was arrested for auto theft as a juvenile, was arrested for running away from home at age 15, was arrested for joyriding prior to service, and was sent to juvenile hall by his father. Additionally, while the Veteran reported to the September 2012 VA examiner that he did not have any significant disciplinary issues during school, he had previously reported during the January 1995 hospitalization that he was suspended four or five times in school for smoking and ditching school. The Veteran also reported to the September 2012 VA examiner that he did not use alcohol prior to enlistment, but his drinking of alcohol increased dramatically during service, which conflicts with his January 1995 report that he began drinking beers as a teenager and the report he made to the February 2011 VA examiner, that he did not abuse alcohol during service. Regardless, the September 2012 VA examiner acknowledged review of the claims file in conjunction with his evaluation of the Veteran and acknowledged that the Veteran was a poor historian. The Board finds that the examiner's claims file review would have put him on notice of the earlier reports regarding disciplinary and legal problems and alcohol use, and that such inconsistencies in the evidence of record were clearly considered by the September 2012 VA examiner, as evidenced by his statement that multiple pieces of information given by the Veteran were at odds with information from previous reports. Weighing against the claim for service connection is the February 2011 VA examiner's opinion that the Veteran did not meet the criteria for an Axis I diagnosis and the April 2013 VA examiner's opinion that it was less likely than not that the Veteran's claimed PTSD incurred in, was caused by, or was aggravated by his time in military service. Also weighing against the claim for service connection is the June 2007 mental health intake assessment, during which the social worker stated that the Veteran was unable to state any symptoms of PTSD other than nightmares; the January 2008 negative PTSD screen and negative PTSD and depression screens in August 2009 and August 2012. However, these screens for PTSD and depression appear to be just that, screens, as opposed to examinations like those performed by the September 2012 and February 2011 VA examiners. Further, the September 2012 VA examiner specifically acknowledged that the Veteran had denied PTSD symptoms according to a January 2008 VA treatment record. Importantly, the question for consideration is whether the Veteran has, at any time since the filing of his claim for service connection, had a diagnosis of PTSD related to an in-service stressor. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The September 2012 VA examination report includes evidence of such a diagnosis. The September 2012 VA examiner, February 2011 VA examiner, and April 2013 VA examiner each provided rationales for their opinions and each are medical professionals. The Board observes that both the September 2012 and February 2011 VA examiners are psychologists, and so are expertly qualified in the pertinent area of medicine to provide an opinion. See Guerrieri, 4 Vet. App. at 470-471. Conversely, there is no indication that the physician who provided the April 2013 opinion has specialized training or education in the field of psychology; rather, she appears to be a podiatrist. Cf. Black v. Brown, 10 Vet. App. 279 (1997) (indicating an opinion may be reduced in probative value, even where the opinion comes from someone with medical training, if the medical issue requires specialized knowledge). While both the September 2012 and February 2011 VA examiners examined the Veteran, the February 2011 VA examiner did not acknowledge review of the claims file. While it appears that she reviewed some VA treatment records (as evidenced by her reference to the June 2007 record), she did not acknowledge claims file review. A review of the claims file is not a mandatory prerequisite for providing an adequate opinion; however, the physician must be fully informed of the pertinent factual premises (i.e., medical history) of the case. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds that claims file review is relevant in this case, where the Veteran is an unreliable historian and the record contains numerous inconsistencies in regard to his reported history. Additionally, while both the September 2012 and February 2011 VA examiners interviewed and conducted examinations of the Veteran, only the September 2012 VA examiner conducted psychological testing. Although the April 2013 VA examiner did not examine the Veteran, she did acknowledge review of the claims file. Confusingly, however, the April 2013 VA examiner referred to 2007 and 2008 mental health examinations finding that it was less likely than not that the Veteran's claimed PTSD was caused or aggravated by his time in service. Perhaps this is a reference to the June 2007 mental health intake assessment, in which the social worker commented that the Veteran did not have symptoms of PTSD other than nightmares, and the January 2008 negative PTSD screen. In any event, as stated above, the September 2012 VA examiner, who rendered a positive opinion regarding the claim for service connection for PTSD, specifically acknowledged review of the claims file, including the Veteran's January 2008 denial of PTSD symptoms. In view of the above, the Board finds that the evidence is at least evenly balanced regarding the question of whether the Veteran has a current diagnosis of PTSD related to his in-service personal assault, if not weighing more in favor of his claim. In cases where the evidence is evenly balanced, the claimant prevails. See Gilbert, 1 Vet. App. at 53-54. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for PTSD is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board acknowledges that the VA treatment records include an Axis I diagnosis of adjustment disorder, not otherwise specified, during the pendency of the appeal. See Clemons, supra. There is no indication, however, that these diagnoses of adjustment disorder were related to the Veteran's military service. Moreover, the September 2012 VA examiner, who reviewed the claims file and CPRS records, was specifically advised in the VA examination request that the examination was to determine whether the Veteran had manifested PTSD or any other acquired psychiatric disability since one year prior to filing his claim for service connection. This examiner diagnosed only PTSD and alcohol dependency in full sustained remission. The Board finds the diagnoses of the September 2012 VA examiner, based as they were on review of the claims file and CPRS records, to be the most persuasive evidence of record as to the nature of the Veteran's psychiatric disability. Accordingly, the Board finds that service connection for a psychiatric disorder other than PTSD is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against entitlement to service connection for a psychiatric disorder other than PTSD, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As for any diagnosis associated with alcohol abuse/dependency during the pendency of this appeal, the Board notes that for claims received after October 31, 1990, compensation shall not be paid if a disability is the result of the Veteran's own willful misconduct or abuse of alcohol. 38 U.S.C.A. §§ 105, 1110; 38 C.F.R. § 3.301(a); VAOPGCPREC 2-98. As the Veteran's claim, which initiated the current appeal, was received in April 2007 the Veteran is not entitled to disability benefits as a result of alcohol abuse/dependency. The law, however, does not preclude a Veteran from receiving compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a Veteran's service-connected disability. Significantly, the February 2011 VA examiner commented that, while the Veteran had a history of significant alcohol and drug abuse, he did not meet the criteria for either of these diagnoses at the time of examination. Similarly, the September 2012 VA examiner's diagnosis was alcohol dependency, full sustained remission. In any event, as the Veteran is being granted service connection for PTSD, the issue of whether his alcohol abuse/dependency is secondary to the service-connected PTSD is moot as it would be rated under the same General Rating Formula for Mental Disorders as is his service-connected PTSD. See Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009) (held that while it was possible for two mental disabilities to have different symptoms and therefore be evaluated separately, if the manifestations of the two mental disabilities were the same, a separate evaluation was not warranted). ORDER Service connection for PTSD is granted. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs