Citation Nr: 1332035 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 07-16 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for paranoid schizophrenia. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from June 22, 1978 to July 10, 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, in which the RO, in pertinent part, denied an application to reopen a claim for service connection for paranoid schizophrenia. In his May 2007 Substantive Appeal (VA Form 9), the Veteran requested a Central Office hearing in Washington, D.C. He cancelled that request in August 2010. Therefore, the Board hearing request is considered withdrawn. See 38 C.F.R. § 20.704(e) (2013). In an October 2011 decision and remand, the Board, in pertinent part, granted the Veteran's application to reopen the claim for service connection for paranoid schizophrenia, and remanded the reopened claim to the Appeals Management Center (AMC) for further development. In April 2013, the Board remanded the claim for additional development. After completing this additional development, the AMC continued to deny the claim. The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In a December 2008 statement, the Veteran stated that he had symptoms of posttraumatic stress disorder (PTSD). Despite this statement, the medical evidence of record since the February 2005 filing of the current claim consistently reflects diagnoses of and treatment for paranoid schizophrenia, and the Veteran has repeatedly asserted that his paranoid schizophrenia is related to service. There is no evidence of a diagnosis of PTSD. On VA examination in November 2011, the examiner reported that the Veteran had been diagnosed with paranoid schizophrenia and stated that he did not have more than one mental disorder diagnosed. Accordingly, the matter on appeal has been characterized as reflected on the title page. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. The Board has also reviewed the Veteran's Virtual VA file and finds that it does not include any additional relevant documents. In May 2013, the Veteran filed a claim for service connection for right and left foot disorders, right and left knee disorders, and paranoid schizophrenia. In the February 2006 rating decision, the RO found that new and material evidence had not been submitted to reopen a claim for service connection for pes planus and in April 2013, the Board denied service connection for right and left knee disorders. Requests to reopen claims for service connection for bilateral pes planus and a bilateral knee condition have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these matters and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. The Veteran's paranoid schizophrenia is not related to service. CONCLUSION OF LAW The criteria for the establishment of service connection for paranoid schizophrenia are not met or approximated. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court have been fulfilled. The Veteran's request to reopen his claim for paranoid schizophrenia was received in February 2005. The Veteran was provided notice of what evidence was required to substantiate his request to reopen the claim, and to substantiate the underlying claim for service connection and of his and VA's respective duties for obtaining evidence in correspondence dated in March 2005. The claim was reviewed and the February 2006 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 Court found that the VCAA notice requirements applied to all elements of a claim. While VA did not provide the Veteran with information regarding the Dingess requirements (specifically, how disability ratings and effective dates are assigned), because the Veteran's claim is being denied, any questions as to the appropriate disability rating or effective date are moot, and there can be no failure-to-notify prejudice to the Veteran. See Dingess, 19 Vet. App. at 484. 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 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 and VA and private treatment records have been obtained and associated with his e-folder. The Veteran was also provided with a VA examination to evaluate his paranoid schizophrenia in November 2011 and a supplemental medical opinion was obtained from the November 2011 VA examiner in June 2013. The claim for service connection for paranoid schizophrenia was remanded in April 2013 to obtain a supplemental medical opinion from the November 2011 VA examiner. As indicated above, this opinion was obtained in June 2013. The June 2013 opinion addresses the etiology of the Veteran's paranoid schizophrenia, is responsive to the April 2013 remand directives, and includes a basis for the examiner's opinion. Thus, the opinion is adequate. 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 record indicates that the Veteran has received disability benefits from the Social Security Administration (SSA). The RO requested records from SSA on several occasions between July 2008 and May 2009 without success. In June 2009, SSA responded that it had not been able to obtain the Veteran's disability file. In July 2009, the RO outlined the efforts it had made to obtain the Veteran's SSA records, and made a formal finding of the unavailability of these records. The Veteran was advised of the unavailability of his SSA records via letter in July 2009. As the RO took all reasonable steps to procure the missing SSA records, the Board finds that an additional remand would serve no useful purpose and would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In August 2009, Dr. B.M., the Veteran's psychiatrist from the New River Valley Community Services PACT Team wrote to the RO that the Veteran was currently enrolled in the program of assertive community treatment (PACT) through New River Valley Community Services, and had been enrolled with the PACT team since his most recent discharge from the state psychiatric facility in February 2009. Dr. B.M. reported that the Veteran was diagnosed with chronic paranoid schizophrenia, and listed his medications. Private treatment records dated from February 2009 to October 2011 reflect that the Veteran continued to be followed by Dr. B.M. and the PACT team for paranoid schizophrenia. While treatment records from the New River Valley Community Services Mental Health Clinic, dated from April 2002 to March 2005, were previously associated with the claims file in April 2005, the evidence discussed above indicates that the Veteran has received more recent psychiatric treatment from this facility. Similarly, a February 2003 Report of Contact reflects that the Veteran wished to reschedule his Decision Review Officer (DRO) hearing scheduled for later that month, as he was hospitalized at Southwestern Virginia Mental Health Institute. While treatment records from this facility, dated in April 1990, were previously associated with the claims file in August 2001, the February 2003 Report of Contact indicates that additional treatment records from this facility are available. Additional records were requested from this facility in September 2005. In response, the Southwestern Virginia Mental Health Institute requested an additional release, which the RO asked the Veteran to provide. The Veteran submitted the additional release to the RO in November 2005, in which he indicated that he was requesting the release of all previous and past treatment records. It is not clear that the RO subsequently requested these records, and no additional treatment records from this facility have been associated with the claims file/e-folder. In December 2008, the Veteran reported that he was again hospitalized at Southwestern Virginia Mental Health Institute, where he had been hospitalized since May 29, 2008. While there is evidence that the Veteran has received private psychiatric treatment through New River Valley Community Services and at the Southwestern Virginia Mental Health Institute which is not currently of record, 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. In a November 2011 letter, the AMC advised the Veteran that it was working on his claim for service connection for paranoid schizophrenia and had requested his treatment records from the Salem VAMC dated from 1979 to 1999. The AMC informed the Veteran that it needed additional evidence from him, and asked that he identify all records of VA and non-VA health care providers who had treated his paranoid schizophrenia. The AMC asked the Veteran to complete a separate form 21-4142 for each non-VA provider from whom he had received treatment if he wanted VA to obtain his records. The Veteran responded by submitting 21-4142s regarding private treatment for his knees and feet and treatment records from New River Valley Medical Group (including mental health treatment). The records from New River Valley Medical Group, dated from February 2009 to October 2011 were obtained and associated with the claims file. Significantly, the Veteran did not submit a release to enable VA to obtain additional treatment records from either New River Valley Community Services or the Southwestern Virginia Mental Health Institute. As the Veteran has not provided an updated release form to obtain additional records from these facilities; it is not possible for VA to obtain them. No further action in this regard is warranted. A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C.A. § 5107(a). While VA has a duty to assist the veteran in substantiating his claim, that duty is not a one- way street. Woods v. Gober, 14 Vet.App. 214, 224 (2000); see also Hurd v. West, 13 Vet.App. 449, 452 (2000) (the Veteran cannot passively wait for help from VA). Further, in response to the June 2013 SSOC, the Veteran submitted a waiver in July 2013, via which he indicated that he did not currently have any additional evidence to submit regarding his appeal. No further action in regard to obtaining additional private treatment records is warranted. Remand is also not required to obtain additional VA treatment records. Treatment records from the Salem VA Medical Center (VAMC), dated from August 1979 to May 1982 have been associated with the e-folder. In a May 2001 VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), the Veteran reported receiving treatment for paranoid schizophrenia at the Salem VAMC from 1979 to 1981. In his February 2005 request to reopen a claim for service connection for paranoid schizophrenia, the Veteran reported that he was seen at the Salem VAMC. In a March 2005 VCAA notice letter, the RO advised the Veteran that there were no medical records for his treatment at the Salem VAMC. March 2005 SHARE screens reflect no discharge summaries, consults, or progress notes from the Salem VAMC. A SHARE screen from September 2005 again reflects no progress notes at the Salem VAMC. In a May 2013 claim for service connection for right and left foot disorders, right and left knee disorders, and paranoid schizophrenia, the Veteran reported receiving treatment at the Salem VAMC in 1978 and ongoing. The May 2013 report of "ongoing" VA treatment does not necessarily indicate that the Veteran has received VA treatment for his paranoid schizophrenia since May 1982; rather the March and September 2005 SHARE screens suggest that he did not receive VA treatment between May 1982 and March 2005. Even if the Veteran had received VA treatment for paranoid schizophrenia since May 1982, in his June 2013 opinion the VA examiner specifically stated that the Veteran's VBMS file and VA medical records had been reviewed. Thus, any treatment records regarding the Veteran's paranoid schizophrenia would have been considered in the VA examiner's etiological opinion. There is also no indication that any additional VA psychiatric treatment records, even if in existence, would include an opinion regarding the cause of the Veteran's paranoid schizophrenia, the matter on which this case turns. To the extent that any outstanding records would merely demonstrate ongoing treatment for paranoid schizophrenia, remand to obtain these records is unnecessary. See generally Morton v. Principi, 3 Vet. App. 508 (1992); Mingo v. Derwinski, 2 Vet. App. 51 (1992) (observing that evidence of a claimant's current condition is not generally relevant to the issue of service connection, absent some competent linkage to military service). 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). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. Analysis The Veteran asserts that he has paranoid schizophrenia related to service. In a February 2001 VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), the Veteran reported that his "whole thinking process changed" when he was on active duty and stated, "when I was going through marine training it affected me psychologically, physically, and emotionally!" In his notice of disagreement (NOD) received in January 2007, the Veteran reported that his paranoid schizophrenia began after returning home from service. He stated in his May 2007 VA Form 9 that he suffered from many sleepless nights from all the stress he was suffering during service and had been told that this is what triggered his paranoid schizophrenia. In his September 2009 VA Form 646, Statement of Accredited Representative in Appealed Case, the Veteran, via his representative, asserted that the stress of military service caused his paranoid schizophrenia and that his symptoms began while on active duty. 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))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and the "nexus" requirement of the three-element test must be met. Id. at 1338-39. Service connection can be granted for certain diseases, including psychoses, if manifest to a degree of 10 percent or more within one year of separation from active service. Such diseases shall be presumed to have been incurred in service even though there is no evidence of disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. According to 38 C.F.R. § 3.384, a "psychosis" includes the following specific disorders: brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified (NOS), schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. However, the provision for presumptive service connection only applies in the case of a veteran who served for ninety days or more of active, continuous service. As the Veteran in this case served for less than ninety days, presumptive service connection is not for consideration. 38 C.F.R. § 3.307(a)(1). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of the inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). 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 law, the Board finds that the preponderance of the evidence is against the claim and service connection for paranoid schizophrenia is not warranted. Service treatment records are negative for psychiatric complaints or treatment. In his March 1978 Report of Medical History at enlistment, the Veteran described his present health as good and indicated by checkmark that he had never had depression or excessive worry or nervous trouble of any sort. On enlistment examination in March 1978, clinical evaluation of the psychiatric system was normal. On June 21, 1978, the examining physician indicated by checked box that the Veteran was qualified for enlistment. Six days after entry into service, a Medical Board recommended the Veteran's separation from service based on a nonacceptable defect, specifically, status post surgical repair of trauma to the left knee with residual lateral instability, which existed prior to entry. In August 1979, the Veteran was admitted to Pulaski Community Hospital after he attempted to commit suicide by stabbing himself. He reported that he had been very depressed over several years and described his depression as growing in intensity, particularly since he had been doing poorly at the community college. The Veteran stated that he knew of no particular reason why he was depressed except that his father had been poisoned when he was 12 years old and this had been bothering him a great deal recently. A note from this hospitalization includes the Veteran's report that he had been depressed for three years. The discharge diagnoses were stab wound to the abdomen and severe depression. In his August 2002 NOD, the Veteran alleged that his thinking process changed on active duty, reporting that he, "thought [he] could see things with a superior vision than others" and that he had been given or was to be given "some kind of Super Human Strength or special power." In his October 2002 VA Form 9, the Veteran reported shaking tremendously and alleged an inability to sleep during service. In a March 2005 statement, the Veteran reported that he was given Valium because when he stood in line he shook. In a December 2008 statement, the Veteran described delusions, sleep disturbances, depression, and nervousness during service. He alleged that, when he was discharged, he started hearing voices, having auditory hallucinations and delusions, and became violent towards his family. He added that he also had symptoms of PTSD. In an October 2009 letter to his congressman, the Veteran alleged that his paranoid schizophrenia started in service and his psychiatrist had told him that it usually started "around teen and up." The Veteran commented that he was 19 years old when he entered service. Post-service private treatment records reflect diagnoses of and treatment for paranoid schizophrenia from April 1990 to October 2011. In November 2011, the Veteran was afforded a VA mental disorders examination. The examiner reported that the Veteran had been diagnosed with paranoid schizophrenia and stated that he did not have more than one mental disorder diagnosed. The examiner commented that there was no indication of any mental health complaints or treatment in the Veteran's brief time in the military. The examiner observed that about a year after discharge, the Veteran had an inpatient psychiatric admission following a suicide attempt, at which time he reported that he had been depressed for three years but did not really know why (the examiner observed that this conflicted with his military entrance report where he reported that he never had any mental health problems and his recent assertion that this brief time in the military was the cause of his mental health struggles). The diagnosis at the time of the psychiatric admission shortly after service was depression; however, the November 2011 VA examiner noted that one of the medications he was on was Thorazine, which is typically used for treating psychosis, and that there was a note indicating that he was having auditory hallucinations, which is a psychotic symptom. Accordingly, the VA examiner stated that this suggested that the Veteran was having schizophrenic symptoms at that time. The VA examiner further noted that records indicated that the Veteran had had numerous inpatient psychiatric admissions over the years, and had been repeatedly diagnosed with paranoid schizophrenia by many different providers and facilities. The examiner opined that the Veteran's schizophrenia was not related to military service, nor was it exacerbated by service. The examiner listed the reasons for his opinion. First, the Veteran spent less than three weeks in service and the vast majority of that was spent in medical hold for his knee issue and simply spending a few days in the military does not cause schizophrenia, which is seen as a biological condition, not caused by any external factors such as stress (which, he commented, the Veteran seemed to have very little of). Second, the examiner observed that no mental health problems were complained of or described in the military and the Veteran had no treatment for about a year after service. Third, the Veteran's description in the psychiatric hospitalization records the year after discharge from service indicated that he did not know the reason for his emotional problems, in other words, according to the examiner, the Veteran made no reference to any excessive stress or problems from his very brief military service in the prior year. Subsequent to this VA examination, records from the Salem VAMC, dated from August 1979 to May 1982 were associated with the claims file. These records reflect that the Veteran received inpatient psychiatric treatment in August and September 1979 following his suicide attempt. Assessments during that hospitalization included paranoid schizophrenia, alcohol hallucination, and depression. An August 1979 vocational counseling consultation sheet reflects that the Veteran reported hearing command hallucinations for one year, with occasional visual hallucinations and persecutory delusions. The Veteran reported on another date during this hospitalization that he had been feeling depressed and hearing voices for approximately one year, since his discharge from the Marines after 16 days of basic training because of a bad knee. In describing the history of his present illness, the Veteran reported that his symptoms dated back to the summer of 1978, when he graduated from high school and joined the Marine Corps. He stated that he was yelled at frequently during basic training. The Veteran reported that he entered the community college after returning home following discharge, but found it difficult and had a hard time concentrating on his work, at which time he started to hear voices in his head. He described continued trouble with voices and beginning to feel like people were out to get him. He also admitted to seeing visual hallucinations. He described feelings of despair and uselessness, including an inability to be successful in the Marines, on the night of his attempted suicide. The physician described the Veteran as having recent failures in school and the Marines and as troubled by "voices" and occasionally seeing things. He commented that the signs and symptoms exhibited by the Veteran might be consistent with the early signs of schizophrenia, coupled with a mild depressive component secondary to situational problems. The Veteran was also hospitalized at the Salem VAMC in July and August 1980 for paranoid schizophrenia with depressive features. The Veteran reported no auditory hallucinations in the past; although he reported that he could be "seeing things" although he was not sure whether this was real or not. Diagnoses during this hospitalization again included paranoid schizophrenia and depression. In light of the fact that the August 1979 VA treatment record, in which the Veteran discussed feelings of depression, in part, due to his discharge from service, was not of record at the time of the November 2011 VA examination, a supplemental opinion was obtained from the VA examiner in June 2013. The VA examiner noted that the Board's remand indicated that there were some additional records, dated in 1979, which had not been reviewed at the time of the November 2011 VA examination. The VA examiner observed that, in some of these records, it was reported that the Veteran made comments about feeling unable to succeed and voices telling him that this was due to his being unable to continue in the military (due to pre-existing knee problems which were not revealed upon entry into service). The VA examiner again reviewed the records, and stated that his prior opinion from November 2011 remained the same. He gave the same reasons for his opinion as had previously been provided in November 2011, but added that, "even though there was a report of [the Veteran] feeling depressed about not being able to finish in the military due to his knee, a feeling of depression (i.e. sadness, regret, disappointment) is NOT the same as a mental disorder and such a feeling does NOT cause mental disorders especially paranoid schizophrenia. Such a feeling would likely be quite normal in that situation. Even if he was sad due to not being able to complete military service, it was not the military that caused the sadness, it was NOT being in the military that may have created some sad feelings (though not a mental disorder)." The VA examiner went on to observe that the Veteran had made conflicting statements regarding his depression. For example, in 1979 he stated that he had been depressed for three years, but he did not report depression on enlistment in 1978. Further, the examiner noted that, in 1979, the Veteran stated that he did not know why he was depressed, but speculated that it could have been due to his father being poisoned when the Veteran was 12. The examiner pointed out that, on VA examination in November 2011, the Veteran was not endorsing symptoms of depression; rather, he was having symptoms of schizophrenia. The examiner commented that the Veteran had no training in mental health disorders and would not likely know what does or does not cause schizophrenia, although he likely knew that a little over a year after military service he was hospitalized due to such symptoms. However, the examiner indicated that the fact that such treatment occurred after the military does not mean that military service caused the disorder. The VA examiner added that he had previously described the current thinking regarding etiology of schizophrenia in the November 2011 VA examination report, and included an article discussing that, as well as many other sources, schizophrenia was thought to be a biologically-based brain condition that manifested with psychiatric symptoms and was thought to be genetically/biochemically based. The examiner then stated that this article indicated that schizophrenia was not caused by things such as spending three weeks in the military, including all but a couple of days on medical hold. He concluded by stating that he was still of the opinion that the Veteran's paranoid schizophrenia was not due to, exacerbated by, or related in any way to his extremely brief time in military service. Recent private treatment records and the November 2011 VA examination report reflect diagnoses of paranoid schizophrenia. Thus, the first element of the service connection claim, a current disability, is satisfied. Hickson, 12 Vet. App. at 253. The Veteran has, at times, reported that his paranoid schizophrenia began during service, and has described symptoms which he attributes to paranoid schizophrenia as occurring during service. However, the Veteran has provided conflicting statements regarding the onset of his psychiatric symptoms. For example, he reported in December 2008 that he experienced delusions, sleep disturbances, depression, and nervousness during service and he asserted in September and October 2009 that his symptoms of paranoid schizophrenia began while on active duty; however, he reported during treatment in August 1979 that he had been feeling depressed and hearing voices for approximately one year, since his discharge from the Marine and in January 2007, he stated that his paranoid schizophrenia began after returning home from service. The Veteran is competent to describe symptoms such as delusions, sleep disturbances, depression, nervousness, and hearing voices. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). However, in light of the inconsistencies in his reports regarding the onset of his psychiatric symptoms, the Board finds the Veteran's reports of psychiatric symptoms beginning in service not to be credible. Caluza, 7 Vet. App. at 511-512. The Veteran has also described psychiatric symptoms prior to service. For example, during treatment in August 1979 he indicated that he had been depressed for three years. Every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C.A. §§ 1111, 1137. In July 2003, the VA General Counsel issued a precedent opinion holding that to rebut the presumption of soundness in 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. See also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). However, despite the August 1979 report of depression for three years, another record from August 1979 reflects that the Veteran reported feeling depressed and hearing voices for approximately one year, since his discharge from the Marine Corps. Significantly, the Veteran indicated in his March 1978 Report of Medical History that he had never had depression or excessive worry or nervous trouble of any sort and clinical evaluation of the psychiatric system was normal on enlistment examination. These medical records generated in conjunction with his enlistment into service are highly probative both as to the Veteran's subjective reports and their resulting objective findings. They were generated with a view towards ascertaining the Veteran's then-state of physical fitness and are akin to statements of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). The evidence does not indicate that the Veteran's psychiatric disorder clearly and unmistakably existed prior to his entrance into active duty. Accordingly, the presumption of soundness is not rebutted and the remaining question is whether his current paranoid schizophrenia is related to his active duty service. The November 2011 VA examiner opined that the Veteran's paranoid schizophrenia was not related to or exacerbated by service. After reviewing the additional VA treatment records regarding psychiatric treatment in 1979, he reiterated his opinion in June 2013. The VA examiner's opinion was based on review of the claims file/e-folder, examination of the Veteran, and consideration of pertinent medical literature. The examiner explained the basis for his opinion, specifically: the Veteran spent less than three weeks in service and the vast majority of that was spent in medical hold for his knee issue and simply spending a few days in the military does not cause schizophrenia, which is seen as a biological condition, not caused by any external factors such as stress; no mental health problems were complained of or described in the military and the Veteran had no treatment for about a year after service; and the Veteran's description in the psychiatric hospitalization records the year after discharge from service indicate that he did not know the reason for his emotional problems, in other words, according to the examiner, the Veteran made no reference to any excessive stress or problems from his very brief military service in the prior year. Even after considering the August 1979 treatment records referencing feelings of depression, in part, due to the Veteran's discharge from service, the examiner specifically stated that a feeling of depression is not the same as a mental disorder and such a feeling does not cause mental disorders, especially paranoid schizophrenia. The VA examiner's opinion is highly probative. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerrieri v. Brown, 4 Vet. App. 467, 470- 71 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). The preponderance of the evidence reviewed is against the claim. The Veteran has not presented or identified any existing, contrary medical opinion that, in fact, supports the claim for service connection. Although the Veteran stated in his May 2007 VA Form 9 that he had been told that his paranoid schizophrenia was triggered by many sleepless nights in service, there is simply no competent medical opinion indicating a relationship between the Veteran's current paranoid schizophrenia and service. The Veteran did not indicate in his May 2007 statement who had told him that his paranoid schizophrenia was triggered by sleepless nights in service, but, even had this statement been made by a medical professional, unsupported assertions of statements from a physician do not, in and of themselves, constitute medical evidence required to substantiate a service connection claim. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Thus, the only informed, competent, and therefore probative opinion on the question of whether the Veteran's current paranoid schizophrenia is related to service weighs against the claim for service connection. In addition to the medical evidence, the Board has considered the Veteran's contention that he has current paranoid schizophrenia related to service. Although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions, such as concerning a form of cancer. See also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (discussing this axiom in a claim for rheumatic fever); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). The Veteran does not have or claim to have any specialized knowledge in the field of medicine. The Board therefore finds that the etiology of his paranoid schizophrenia is beyond his competence. Moreover, the question of etiology of this condition is complex in nature. Therefore, to the extent he has asserted that he has paranoid schizophrenia related to service, the Board finds such assertions to be of little probative value, especially in relation to the VA examiner's opinions, as the Veteran is not competent to opine on this complex medical question. His contentions regarding etiology of his current paranoid schizophrenia are outweighed by the medical evidence of record, specifically the opinions of the VA examiner. For all the foregoing reasons, the claim for service connection is denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). (CONTINUED ON NEXT PAGE) ORDER Service connection for paranoid schizophrenia is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs