Citation Nr: 1333595 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 99-03 858A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1975 to April 1981 and from May 1991 to June 1991. She also completed service with the U.S. Air Force Reserves from May 1983 to March 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1998 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which, in pertinent part, denied the Veteran's claim for service connection for a psychiatric disorder. Jurisdiction of the claims file was subsequently transferred to the RO in North Little Rock, Arkansas. The Veteran provided testimony at a hearing before the undersigned Veterans Law Judge (VLJ) at the North Little Rock RO in December 2009. A transcript of this hearing has been associated with the claims folder and reflects that the Veteran was afforded an extensive opportunity to present hearing testimony, evidence, and argument on the issue on appeal. The Board remanded the case to the agency of original jurisdiction (AOJ) for further development in August 2005, June 2009, June 2010, and July 2012. The AOJ has now returned the claim to the Board for further appellate review. As discussed further herein, the Board finds that the AOJ substantially complied with the remand orders with respect to the claim decided herein and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In May 2013 the Board requested a specialist medical opinion from the Veterans Health Administration (VHA). See 38 C.F.R. § 20.901(a) (2013); see 38 U.S.C.A. §§ 5109(a), 7109(a) (West 2002). The report, dated in July 2013, has been associated with the claims file. Although a July 2013 VA report of telephone contact within the claims file reflects that the Veteran reported that she would be submitting additional evidence, no further evidence or argument was received from, or on behalf of, the Veteran with the exception of an October 2013 brief submitted by her authorized representative. The October 2013 brief does not indicate that the Veteran has any additional evidence or argument to submit. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal, which has also been reviewed by the Board. This virtual file contains VA treatment records that are not contained in the paper claims file, but were reviewed and considered by the AOJ in a March 2013 supplemental statement of the case. FINDINGS OF FACT 1. No acquired psychiatric disorder was noted at the time of the Veteran's enlistment into active duty in 1975 and there is no clear and unmistakable evidence that any acquired psychiatric disorder pre-existed the Veteran's periods of active duty service. 2. An acquired psychiatric disorder is not shown to be causally or etiologically related to-to include aggravated by-any disease, injury, or incident in service, to include active duty for training (ACDUTRA); a psychosis did not manifest within one year of the Veteran's discharge from active duty service; and an acquired psychiatric disorder is not caused or aggravated by a service-connected disability. CONCLUSION OF LAW An acquired psychiatric disorder was not incurred in or aggravated by the Veteran's ACDUTRA or active duty military service, may not be presumed to have been incurred in or aggravated by service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 101(24), 106, 1101, 1110, 1112, 1116, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a December 1997 letter, sent prior to the initial unfavorable rating decision and the enactment of the VCAA, and January 2007 and November 2008 letters advised the Veteran of the evidence and information necessary to substantiate her claim for service connection as well as her and VA's respective responsibilities in obtaining such evidence and information. The January 2007 and November 2008 letters also informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Although the 2007 and 2008 letters were issued after the initial rating decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that VA can cure such a timing problem by readjudicating the Veteran's claim following the issuance of a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the 2007 and 2008 letters were issued, the Veteran's claims were readjudicated in supplemental statements of the case issued in April 2009, November 2011, and March 2013. Therefore, any defect with respect to the timing of the VCAA notices has been cured. Relevant to the duty to assist, available service treatment records, VA and private treatment records, and records from the Social Security Administration (SSA) have been obtained and considered. The Board notes that not all of the Veteran's treatment records from her reserve service and second term of active duty service have been associated with the claims file. The claims file reflects that the AOJ has made numerous attempts to obtain these missing records from the National Personnel Records Center (NPRC), the Headquarters of the U.S. Air Force Reserves, the Air Reserve Personnel Center, as well as from the Veteran personally. In a Formal Finding of Unavailability, the AOJ noted that the following efforts to obtain these missing records were attempted: (1) Air Reserve personnel Center, (2) PIES request, and (3) HQ ARPC. It thus appears the AOJ properly searched alternative sources in an attempt to assist the Veteran in proving her claims. See Moore v. Derwinski, 1 Vet. App. 401 (1991) (holding that the heightened duty to assist a Veteran in developing facts pertaining to her claim in a case in which service treatment records are presumed destroyed includes the obligation to search for alternative medical records). The AOJ also issued a Formal Finding of Unavailability of these records in November 2008 and subsequently notified the Veteran as to the status of her records in accordance with 38 C.F.R. § 3.159(d). The Board notes both that the Veteran testified in December 2009 that she received psychiatric treatment during her second term of active duty service and the claims file reflects no direct inquiry to the clinic or hospital at Charleston Air Force Base where she was stationed in 1991. However, as the Veteran did not indicate whether the psychiatric treatment was provided by a military or private clinician, she did not provide sufficient information for VA to identify and locate any such records. See 38 C.F.R. § 3.159 (c)(1)(i). Regardless, in the event that she was claiming treatment by a military psychiatrist, the Board notes that although the VA Adjudication Manual advises that in-service mental health treatment records are maintained by the treating facility (rather than with traditional service treatment records), it also advises that such records are destroyed five (5) years after the case is closed. M21-1MR IV.ii.1.D.14.a. Further, the Board, as discussed in more detail below, has found the Veteran not credible in her accounts as to when she began receiving mental health treatment; her hearing testimony as to receiving such treatment "every two to three months" while on active duty is patently incredible as she served on active duty for less than one month in 1991 during her second term of active duty service. See Jackson v. Veterans Administration, 768 F.2d 1325, 1331 (1985); Pensaquitos Village Inc. v. National Labor Relations Board, 565 F.2d 1074, 1078 (1977) (presiding officials are owed deference as to determinations of witness credibility). An analysis of the evidence of record reveals that the Veteran began receiving psychiatric care shortly after service from private practitioners whose treatment notes are associated with the claims file. However, when, as here, service records are lost or missing through no fault of the Veteran, VA has a heightened duty to consider the applicability of the benefit of the doubt rule and to assist a claimant in developing a claim. Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005), citing Russo v. Brown, 9 Vet. App. 46, 51 (1996). See also Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). However, the duty to assist is not a one-way street. Woods v. Gober, 14 Vet. App. 214, 224 (2000). A claimant is responsible for cooperating with VA in the development of a claim. Id.; 38 U.S.C.A. § 5107(a). Strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). As noted in the Introduction, although a July 2013 VA report of telephone contact within the claims file reflects that the Veteran reported that she would be submitting additional evidence, no further evidence or argument was received from, or on behalf of, the Veteran with the exception of an October 2013 brief submitted by her authorized representative. The October 2013 brief does not indicate that the Veteran has any additional evidence or argument to submit. Therefore, the Board finds that neither the Veteran nor her representative has sufficiently identified any additional, outstanding records that have not been requested or obtained. Additionally, the Veteran was afforded a VA mental disorders examination in July 2010 with addendum opinions issued in August 2012 and January 2013 and an expert opinion was obtained in July 2013. The Board finds that the VA examination, read with the addendum opinions and expert opinion, is adequate to decide the issue. Although the July 2010 examination does not discuss whether any current psychiatric disorder may be etiologically related to the Veteran's active duty service (instead discussing possible etiological relationships to non-service-connected disorders), the January 2013 addendum opinion and July 2013 expert opinion (discussing possible aggravation of any pre-existing disability), read together, reflect a thorough nexus analysis. The Board notes that the 2010 examiner interviewed and examined the Veteran and also provided the 2012 opinion; the 2010/2012 and 2013 examiners/expert reviewed the record, to include her available service treatment records. The ultimate opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and reflect rationales relying on, and citing to, the records reviewed. Moreover, the examiners and the expert offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. As indicated previously, the Veteran testified before the undersigned VLJ in December 2009. A Veterans Law Judge who conducts a hearing must fulfill the following two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The representative and the undersigned asked questions to ascertain information to substantiate the Veteran's service connection claim and draw out relevant evidence. Moreover, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor have they identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the element (nexus to service) necessary to substantiate the claim for service connection and the testimony of the Veteran and her representative demonstrate actual knowledge of what is necessary to substantiate her claim for benefits. Furthermore, she has been provided multiple letters informing her of the elements of service connection and the Board has remanded the appealed issue on four occasions, and obtained an expert opinion in July 2013, in order to ensure that her claim was fully and properly developed. As such, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and finds that any error in notice provided during the Veteran's hearing constitutes harmless error such that attempting any remedy would be "an idle and useless formality." NLRB v. Wyman-Gordon Co., 394 U.S. 759, 766 n. 6 (1969). The Board remanded this case in August 2005, June 2009, June 2010, and July 2012 in order for the AOJ to provide the Veteran with a hearing, afford her an examination, and further develop the claim by assisting her in gathering additional evidence to specifically include records from the SSA, missing service treatment records, and additional VA and private records. The record reflects that a hearing was held in December 2009 and the Veteran was afforded an examination in July 2010, with addendum opinions issued in August 2012 and March 2013. SSA records and additional VA and private records have been associated with the claims file and, as discussed above, the AOJ has taken all appropriate actions to attempt to recover the outstanding treatment records. The AOJ also issued April 2009, November 2011, and March 2013 supplemental statements of the case reflecting readjudication of the claim. Therefore, the Board finds that the prior remand directives have been substantially complied with such that no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini, 1 Vet. App. at 546; Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis Under relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1110, 1131. Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110. ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserves. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full-time duty performed by a member of the Reserves or the National Guard of any State. 38 C.F.R. § 3.6(d). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. According to 38 C.F.R. § 3.384, the term "psychosis" includes a 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. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In the instant case, while the Veteran has a diagnosed psychiatric disorder, such is not defined as a psychosis and, therefore, the provisions at 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 are not for application. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Although the record does reflect substance abuse as one of the Veteran's psychiatric diagnoses and indicates that she may have experienced some psychiatric symptoms secondary to a substance abuse disorder, service connection may not be granted for disability incurred or aggravated as the result of abuse of alcohol or drugs for claims, like the Veteran's, that were filed after October 31, 1990. 38 C.F.R. § 3.301. In Allen v. Principi, 237 F.3d. 1368, 1376-78 (Fed. Cir. 2001), the Federal Circuit clarified that 38 U.S.C.A. § 1110 authorizes disability compensation for alcohol-abuse related disability only when such abuse arose "secondarily from or as evidence of the increased severity of a non-willful misconduct, service-connected disorder." Id. at 1378. As the Veteran is not service-connected for any disabilities and no claim for service connection for substance abuse can be granted, her claim cannot be granted on a secondary basis as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). A Veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Only such conditions as are recorded in examination reports are considered as noted. 38 C.F.R. § 3.304(b). History of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b) (1). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 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. 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. VAOPGCPREC 03-2003; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). In deciding a claim based on aggravation, after having determined the presence of a pre-existing condition, the Board must first determine whether there has been any measured worsening of the disability during service and then whether this constitutes an increase in disability. See Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. 1153; 38 C.F.R. 3.306. Certain evidentiary presumptions, such as the one regarding the presumption of sound condition when entering service, but also the presumption of aggravation during service of pre-existing diseases or injuries that undergo an increase in severity during service, and the presumption of service incurrence for certain diseases such as psychoses, that manifest to a degree of disability of 10 percent or more within a specified time after separation from service (generally one year) are provided by law to assist Veterans in establishing their entitlement to service connection for a disability or disabilities. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304(b) , 3.306, 3.307, 3.309(a). Notably, however, the advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA). However, for Veterans who have achieved "Veteran" status through a prior period of service and claim a disability incurred only during a later period of ACDUTRA, the presumption of soundness applies only when the Veteran has been "examined, accepted, and enrolled for service" and where that examination revealed no "defects, infirmities, or disorders." Smith v. Shinseki, 24 Vet. App. 40, 45-46 (2010). In the instant case, there is no specific entrance examination for her period(s) of ACDUTRA in question. Thus, the presumption of soundness does not apply for such period(s) of ACDTURA. In each case where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of service as shown by the service record, the official history of each organization in which such Veteran served, service treatment records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). However, although all evidence associated with the claims file has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Here, service records reflect that the Veteran was evaluated as psychiatrically normal at the time of her enlistment examination in 1975. On a contemporaneous self report of medical history, she denied any sort of nervous trouble. In-service gynecological records reflect that the Veteran experienced some depression secondary to her use of a specific oral birth control pill, but an April 1977 note states that depression dissipated upon discontinuance of the medication. Treatment notes also reflect that she was involved in a motor vehicle accident in January 1980, but did not experience any head injury or loss of consciousness at that time. Rather, she had "back pain only." An October 1980 gynecological treatment note specifically observes that the Veteran continued to deny any depression since discontinuing oral birth control pills. In December 1980, the Veteran was examined for purposes of separation from her first term of active duty service. The examination report and an accompanying self report of medical history both reflect no psychiatric diagnoses, treatment, or complaints. The examiner specifically noted that she denied a personal or family history of psychosis. A report from a subsequent reserve examination conducted in April 1983 again reflects that the Veteran was psychiatrically normal and she again denied any nervous trouble on a contemporaneous self report of medical history. Private records associated with the claims file reflect that the Veteran was seen in November 1989 for surgical treatment of a back disorder incurred in April of that year. The treatment record states that she reported that she was not taking any medications and did not have any 'remarkable' health complaints. Although no service treatment records are available from the Veteran's brief second term of active duty service, subsequent reserve records do not reflect any mental health problems until after she experienced an injury at her civilian job in October 1991. Service records and associated private treatment records reveal that the Veteran tripped and fell during the course of her employment and experienced injury to her forearms, neck, and head. Service records reflect the date of the incident as October 21, 1991, private records identify the date as October 22, 1991, and the Veteran informed some providers that the incident occurred in 1992, but all sources plainly reflect that she was engaged in civilian employment at the time. A July 1993 private neuropsychological evaluation reflects that the Veteran was evaluated for residuals of the October 1991 accident. The clinician observed that the Veteran reported becoming "irritable and grumpy" after the accident and was being treated for depression via a prescription of Paxil that had been initiated one year and two months prior. A September 1993 neuropsychological evaluation observes that the Veteran had painful physical symptoms after the work accident and was being treated for the "psychological components of her chronic pain disorder." A December 1993 follow up note reflects assessments of neurovegetative symptoms of depression and psychophysiological correlates of anxiety. That follow-up assessment of the "head injury sequelae" also reflects that the Veteran denied personality or behavior changes other than mild depression and mild anxiety. In May 1994, the Veteran's private primary doctor, Dr. Reyna, noted that she had a history of substance abuse. Dr. Reyna wrote a June 1994 letter detailing the Veteran's past medical history and treatment. She observed that the Veteran took two different prescription medications that increased her concentration and improved "her depression secondary to her head injury." Dr. Reyna diagnosed her with a closed head injury secondary to her work injury with problems including mood changes. Although the Veteran had received a military recommendation in May 1994 that described her as a highly capable individual, an October 1996 narrative summary of her post-accident health reflects that she experienced reflex sympathetic dystrophy and closed head injury and was found not qualified for service as a result of the "current medications used to control the above mentioned disorders." The summary specifically noted medications used for sleep, concentration, and pain control. Subsequent treatment notes from Dr. Reyna continue to reflect diagnosis of, and treatment for, depression, as well as her other disabilities. In August 2000, she observed an increase in the Veteran's depression as the result of her lack of income. The Veteran reported to VA for assistance in April 2001 and a social work note reflects that the Veteran stated that she had been medically discharged from service as the result of a head injury experienced while on duty in 1992. Although the Veteran wrote to VA in October 2001 and contended that she experienced the head injury while on active duty, she also sought VA social work assistance in October 2001 and reported that all of her "problems" date back to a "head injury she received in 1992 when she tripped over a pallet at work and struck her forehead on the ground." The Veteran was afforded a VA psychiatric evaluation in late October 2001 "to assist with her application for Social Security Disability." The evaluation report reflects that the Veteran reported first experiencing problems after falling and hitting her head in 1992. The clinician diagnosed the Veteran with major depressive disorder and mild alcohol abuse. In January 2002, the Veteran was admitted for inpatient VA mental health treatment "for what appeared to be mania secondary to bipolar disorder." She was assessed with alcohol dependence, in partial remission, as well as bipolar disorder. The clinician noted that the Veteran also reported depression and attention deficit disorder since 1994. A June 2002 VA treatment note reflects diagnoses of alcohol dependence in partial remission, bipolar disorder, and attention deficit disorder by history. The report of a July 2003 psychological evaluation conducted in regard to the Veteran's claim for SSA benefits reflects that the psychologist determined that the Veteran was a reliable historian. The report also reflects that the Veteran informed the psychologist that she was first diagnosed with bipolar disorder in January 2002 and reported a history of recurrent depression and manic episodes since "1992 after sustaining an on-the-job head injury." The Veteran informed the psychologist that she was first diagnosed with, and treated for, mental disorders following that head injury. After interviewing and examining the Veteran, the psychologist diagnosed her with bipolar disorder, mixed type, with psychotic features and observed elements of agitated depression and disturbances in concentration. VA treatment records continue to reflect treatment for the previously diagnosed disorders. However, although July 2008 and January 2009 VA mental health evaluations again reflect diagnoses of bipolar disorder and alcohol dependence, they note alcohol dependence as in full sustained remission. A July 2009 note reflects that the Veteran reported she did not have any bipolar symptoms until after a 1992 head injury. An October 2009 VA treatment note describes her mood disorder as "secondary to head injury." As noted above, the Veteran testified before the below signed Veterans Law Judge in December 2009. She reported experiencing a motor vehicle accident, with resulting back and neck injuries, during her first term of active duty service. She testified that after leaving her first term of active duty service, she got treatment for depression prior to re-enlisting in the reserves in 1983. She stated that she was not surprised because depression "kind of runs on [her] mom's side of the family." The Veteran contended that her depression was minor at that time, but got much worse when she returned to active duty. Although the Veteran admitted that her subsequent head injury was a civilian, work-related, injury, she, through her representative, contended that the results of that head injury were "contributed to" by neck and back disabilities that she contended resulted from her prior in-service car accident. [The Board notes, parenthetically, that the Veteran's claims for service connection for lumbar and cervical disabilities were denied in a July 2012 Board decision.] The Veteran was afforded a VA mental disorders examination in July 2010. The examiner noted that he had reviewed her claims file prior to the conduct of the examination. He stated that the Veteran reported that her mother had received mental health treatment and her brother had depression. After examining her, the examiner provided a diagnosis of bipolar disorder and stated that it was not etiologically related to her back and neck complaints. He also noted that the Veteran reported a family history of mood problems, "which would argue against a diagnosis of mood disorder secondary to head injury." He also reported that her symptoms had "persisted for years." This same examiner re-reviewed the Veteran's claims file in 2012 and more specifically addressed her clinical history. The examiner noted that he could find no evidence of mental disability prior to 1991 except for 1981 transient depression due to birth control pills. He opined that the etiology of the condition was unclear as the Veteran had a history of head injury and had reported a family history of mood disorder, but he stated that it likely began between 1991 and 1994. A different VA mental disorders examiner reviewed the Veteran's claims file in January 2013. This examiner summarized the Veteran's treatment history and the timeline of her documented complaints and treatments. Based on that evidence, the examiner stated that it was less likely than not that the Veteran's diagnosed psychiatric conditions (depression and bipolar disorder) were incurred in, or aggravated by, her active duty or ACDUTRA. The examiner also opined that no mental disorder clearly and unmistakably pre-existed her entry into active duty service in May 1991 and, based on the private treatment notes by Dr. Reyna, estimated that her mood disorder symptoms initially began approximately one year later in 1992. As noted above, the Board obtained an expert opinion in July 2013. The expert observed that the Veteran was first diagnosed with bipolar disorder in 2002, and, as such, that disorder did not pre-exist any of the Veteran's terms of military service. In regard to depression, the expert noted that service treatment notes from the first period of active duty service reflect only transient depression as the result of a side effect of birth control medication. Although noting private providers' observations of discouragement and depression in the 1990s, the expert determined that those observations did not conflate to psychiatric diagnoses. Specifically, the expert reviewed the treatment notes, noted that the described symptoms could occur in a depressive disorder, but were not, together, enough to qualify for a diagnosis of depressive disorder, and observed a lack of formal psychiatric diagnoses. The expert also commented that the Veteran's treating physician noted in October 1996 that her medications were used for pain control, concentration, and sleep and, as such, were not considered psychotropic; the expert explained that statement meant that any prescribed antidepressants "were not being used to treat a depressive disorder." Based on his review and interpretation of the records, the expert opined that it was not likely a depressive disorder was incurred in active duty or ACDUTRA service. In specific regard to a "mood disorder," the expert specifically observed that no formal diagnosis of major depressive disorder was rendered until 2001 and noted that, prior to that time, a mood disorder was discussed by clinicians in reference to head injury sequelae or substance abuse. He opined that "the most appropriate mood disorder diagnosis during the appellate period in question that the Veteran might have qualified for was Substance Induced Mood Disorder," but the record did not reflect that she would have met clinical guidelines for diagnosis of mood disorder during active duty or ACDUTRA service. As the expert determined that the Veteran would not have qualified for diagnosis of bipolar disorder, depression, or mood disorder, during her active duty service or her ACDUTRA, he also opined that it was not as likely as not that any of those disorders had been aggravated by any of the Veteran's service. The Veteran has primarily contended that she is entitled to service connection for psychiatric disorders, specifically depression and or bipolar disorder, which either began during, or were aggravated by, her military service. However, the Board finds below that the probative evidence is against her claim and service connection is not warranted. 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). 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. 38 C.F.R. § 3.159; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Veteran's service treatment records reflect that she experienced some depression as the side effect of a medication taken during her first period of active duty service. However, she has not contended that depression continued or that it led to her currently diagnosed psychiatric disorders. Not only did the Veteran specifically testify in December 2009 that she did not have any psychiatric disabilities directly resulting from her first period of active duty service, but the competent medical evidence of record contraindicates any such finding. In this regard, the in-service treatment notes refer to her medication-induced depression as having dissipated when she stopped the prescription; she was examined as normal at the time of her discharge from her first term of active duty service; she completed a self report of medical history at the time of her first discharge and explicitly denied having any psychiatric problems at that time; and the 2012 VA examiner and July 2013 expert determined that specific bout of depression was a medication side effect that had resolved prior to her discharge. 38 C.F.R. § 3.159(a)(1). Although the Veteran testified that she did not have any depression directly resulting from her first period of active duty service, she contended at the hearing that she developed depression after that service and that her subsequent depression was aggravated during her second term of active duty service. She specifically alleged that she developed, and was treated for, depression in between her discharge from active duty in April 1981 and her enlistment in the reserves in June 1983; she stated that depression ran in her family. However, she has not identified any such treating clinician and the pertinent evidence of record, to include her own lay statements, does not support that contention. Specifically, on the Veteran's 1981 discharge examination, the examining clinician noted that she denied a personal or family history of psychosis; she again denied experiencing any nervous trouble in 1983 when she enlisted in the reserves. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). In regard to her contention that she had depression upon entering her second term of active duty service (May 1991 to June 1991), and that was aggravated by that service, the Board again notes that every person employed in such active service is presumed in sound condition except as to defects or disorders noted at the time of 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. 38 U.S.C.A. § 1111. Here, the Veteran's service treatment records from her second period of service are not available, but the Board has found her not credible in her account of when her symptoms began and a 2013 VA examiner and a 2013 expert specifically determined that her psychiatric disorder did not pre-exist her 1991 active duty service. Therefore, in the absence of clear and unmistakable evidence that such disorder existed prior to her 1991 re-enlistment, the Board finds that the presumption of soundness attaches. The evidence also fails to show that her acquired psychiatric disorder is otherwise related to such second period of active duty service or to her ACDUTRA. In this regard, the medical evidence of record reflects that the Veteran's mental disorders began after the second period of active duty service, and are not related to such period of service or her ACDUTRA service. Moreover, while she has made conflicting statements about when her mental disorder began, she has consistently indicated that it began after her period of active duty in 1991. Specifically, when she filed her claim for service connection in November 1997, she indicated on the claims form that her problems began in October 1991 and that she had been treated since 1993. She also informed multiple VA and private clinicians that she did not experience any mental disorder symptoms until after her October 1991 head injury - as detailed above, clinicians noted that she reported such a history in December 1993, June 1994, October 1996, April 2001, October 2001, January 2002, and July 2003. Although lay evidence may also be competent to establish medical etiology or nexus (Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009)), VA "may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board has a duty to assess the credibility of the evidence and finds the Veteran's assertions lose credibility and persuasiveness in light of the other evidence of record. Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence of the in-service event -see Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006)- but the Board may discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran has also contended - on her original claims form, in statements to VA social workers in April 2001, and in an October 2001 written statement - that she experienced the October 1991 head injury while she was on duty. However, she rescinded that contention during the December 2009 hearing, indicating the she was mistaken, and testified that the injury occurred "in the civilian world." Her application for SSA disability benefits as well as her multiple statements to various health care providers also reflect that the head injury occurred on her civilian job. As she has only contended that the incident occurred during military service in communications directly related to the receipt of benefits, and that contention conflicts with her other statements as well as the other evidence of record, the Board finds it not credible. Regardless, the Board notes that the Veteran's service records reflect that the only type of service she completed in October 1991 was inactive - thus whether or not she was working as a civilian would not matter since a psychiatric disorder is a disease rather than an injury. See 38 C.F.R. § 101(24) (the only diseases that may be service-connected for incurrence during INACDUTRA are acute myocardial infarction, cardiac arrest, or cerebrovascular accident). In regard to the competent medical evidence of record, the Board again notes that multiple VA and private health care providers have attributed the Veteran's symptoms to her October 1991 head injury and there is no clinical evidence of a mental disorder (other than the transient medication-related depression in her first term of service) prior to the occurrence of that head injury. Moreover, the January 2013 VA examiner opined that it was less likely than not that the Veteran's diagnosed psychiatric conditions (depression and bipolar disorder) were incurred in, or aggravated by, her active duty or ACDUTRA. That opinion is supported by the review and opinion of the 2013 expert. As detailed above, the expert also determined that no psychiatric disability was incurred or aggravated during, or as a result of, any portion of the Veteran's military service. Both of those clinicians reviewed the record and noted the Veteran's treatment history. Although the examiner determined that, based on review of private records, the best estimate of onset of mood disorder was May 1992, the Board notes that is over one year after the end of the Veteran's second period of active duty. Moreover, the expert explained that mood disorder was discussed by private clinicians in reference to head injury (civilian) sequelae or substance abuse (for which service connection cannot be granted) and that, regardless, the private records that referenced mood disorder did not show that she would have met clinical (DSM-IV) guidelines for diagnosis of mood disorder during active duty or ACDUTRA service. Both the examiner and the expert found that, based on the totality of records that it was less likely as not that the Veteran's diagnosed psychiatric conditions were incurred in or aggravated by the Veteran's ACDUTRA service. In evaluating the evidence of record, the Board places great probative weight on the 2013 VA examiner's opinion and the 2013 expert's opinion regarding the etiology of the Veteran's psychiatric disorders as those clinicians issued opinions that reflect consideration of all the evidence of record and citations to relevant data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The opinions are not contradicted by any evidence in the claims file other than the Veteran's lay assertions, which the Board has found not credible. Further, the opinions are supported by the clinical observations of VA, private, and SSA physicians, as detailed above. Because these opinions constitute the most probative evidence of record, the Board finds such evidence determinative on the question of etiology. The Board has considered the Veteran's lay statements that her mental disorders are related to her military service. However, she, as a lay person, is not competent to render an etiological opinion. In this regard, the question of etiology of a psychiatric disorder involves a medical subject concerning internal mental processes extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is non-probative evidence. See Jandreau, supra; see also Woehlaert, supra. Furthermore, the Board has found the Veteran's statements regarding when and how she incurred any psychiatric disorder to be not credible as they are inconsistent with the other evidence of record. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine, but the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. As such, that doctrine is not applicable in the instant appeal, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for an acquired psychiatric disorder is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs