Citation Nr: 1333596 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 05-07 941 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1978 to October 1978. This case was previously before the Board of Veterans' Appeals (Board) on appeal from a July 2004 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). In December 2011, the Board reopened and denied a claim for service connection for an acquired psychiatric disorder. Subsequently, the Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In September 2012, the Court granted a Joint Motion for Partial Remand (JMPR) and issued an Order remanding the Board's December 2011 decision for compliance with instructions provided in the JMPR. In accordance with the JMPR, the Board remanded the claim for additional development in January 2013. In addition, in June 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. A September 2013 brief submitted by the Veteran's authorized representative indicates that he has no additional evidence or argument. FINDINGS OF FACT 1. There is insufficient evidence of a chronic psychiatric disorder during service or of a psychosis within one year after service; such disorder was not noted upon entry into service and there is no clear and unmistakable evidence that such disorder pre-existed service. 2. The Veteran's lay assertions regarding in-service and post-service psychiatric symptomatology are competent and credible, but competent medical evidence reflects they are attributable to a substance abuse disorder. 3. The evidence does not demonstrate that the Veteran incurred a superimposed psychiatric disease or injury upon his substance abuse disorder during service. CONCLUSION OF LAW An acquired psychiatric disorder was not incurred in, or aggravated by, service nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1111, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(b), 3.307, 3.309, 4.9, 4.127 (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 June 2004 letter, sent prior to the initial unfavorable rating decision, generally advised the Veteran of the evidence and information necessary to reopen and substantiate a claim for service connection as well as his and VA's respective responsibilities in obtaining such evidence and information. A letter sent to the Veteran in March 2009 reiterated that information and 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 2009 letter was 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 2009 letter was issued, the Veteran's claim was readjudicated in supplemental statements of the case issued in April 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, service treatment records and post-service VA and private treatment records, as well as Social Security Administration (SSA) records, reports from VA examinations conducted in June 2005 and May 2009, and expert opinions dated January and June 2011, and July 2013 have been obtained and considered. However, the Board notes that, as stated in the JMPR, an October 1995 VA treatment note reflects a VA clinician's observation that the Veteran had been psychiatrically examined 58 times, but VA treatment records associated with the claims file do not reflect that number of examinations or otherwise reveal what that clinician counted to arrive at the number 58. Subsequently, VA undertook additional records searches and obtained additional records. Although the record still does not reflect 58 psychiatric examinations, the VA treatment notes within the claims file appear complete and there is documentation that the AOJ (here the Appeals Management Center (AMC)) made all appropriate attempts to recover any outstanding service records. Further, as multiple inquiries have been made to obtain available records, and neither the Veteran nor his representative have identified any outstanding records, the Board finds that any further efforts to obtain these records would be futile. Therefore, the Board finds that VA has satisfied its duty to assist. Additionally, the Veteran was afforded multiple VA psychiatric examinations. Most recently, he was examined in May 2009 and three expert opinions were subsequently added to the claims file. The Board finds that the 2009 VA examination, read with the later VHA expert opinions and in light of the prior opinions of record, is adequate to decide the issue. The Board notes that the examiner clearly stated that the opinion was based on interview of the Veteran and review of the claims file and reflects analysis of the medical evidence therein. Further, the subsequent expert opinions rendered regarding the relationship between the Veteran's current diagnosis and in-service experiences were plainly rendered based on those clinicians' medical trainings, clinical experiences, and interpretations of the Veteran's clinical findings as well as their analyses of medical evidence in the file. Moreover, the clinicians 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). 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. The Board remanded this case in February 2009 and January 2013 in order for the RO/AMC to ensure that the Veteran had been afforded appropriate notice, afford him additional VA examination, and ensure that all identified and available records were associated with the claims file. The record reflects that VA has mailed the Veteran adequate notice, made all appropriate efforts to obtain outstanding records, afforded the Veteran multiple examinations, obtained multiple specialist opinions, and issued April 2011, and March 2013 supplemental statements of the case reflecting readjudication of the claim after each remand. 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 also 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 v. Derwinski, 1 Vet. App. 540, 546 (1991); 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 his 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. Here, the Veteran contends that he experiences current psychiatric disability either as incurred during, or aggravated by, his active duty service. 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; 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)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the evidence reflects diagnosis of schizo-affective disorder - i.e. a psychosis (38 C.F.R. § 3.384), which is a disorder recognized as chronic under 38 C.F.R. § 3.309(a) - the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are applicable. 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). However, here the Veteran does not contend, and the evidence does not otherwise indicate, that he experiences psychiatric disability as the result of a service-connected disability. Although the claims file does reflect that psychiatric disability may exist secondary to a substance abuse disorder, service connection for substance abuse is not in effect here and pertinent regulation provides that a claimant's own abuse of alcohol or drugs (a substance abuse disability) is precluded for purposes of all VA benefits for claims, such as the Veteran's, that were filed after October 31, 1990. VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (1999); see also VAOPGCPREC 2-98, 63 Fed. Reg. 31,263 (1998). 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. Temporary or intermittent flare-ups of the pre-existing condition during service are not sufficient to be considered aggravation unless the underlying condition, as contrasted to symptoms, has worsened. Crowe v. Brown, 7 Vet. App. 238, 247- 48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). Accordingly, "a lasting worsening of the condition" - that is, a worsening that existed not only at the time of separation but one that still exists currently - is required. See Routen v. Brown, 10 Vet. App. 183, 189 n. 2 (1997); see also Verdon v. Brown, 8 Vet. App. 529, 538 (1996). 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). Upon examination at the time of entrance in to service, March 1978, a military examiner determined that the Veteran had no neurologic or psychiatric abnormalities. The Veteran also denied "nervous trouble of any sort" on an accompanying self report of medical history, although he reported taking Darvon and Valium "occasionally." The physician who reviewed the self report noted in a comment box that those two medications were used "very rarely for mild insomnia, not addicted." The following month, the Veteran reported to a military medical center seeking a refill of Valium and Darvon - he informed the practitioner that he used those medications to treat anxiety, but the practitioner denied him refill. In July 1978, the Veteran requested a psychiatric consultation as well as discharge "in the best interest of the Navy," but a mental status examination revealed no delusions or hallucinations - the Veteran was alert, oriented, appropriately dressed and his mood and speech were normal; the clinician noted no psychomotor agitation or retardation and no evidence of a formal thought disorder. The report states that he was ordered to return to duty as no psychiatric disorder was present at that time. Approximately a week later, another note reflects that the Veteran reported first using LSD and PCP in 1969 and complained of an LSD flashback and stated that he wanted out of the Navy. However, a clinician again found that he was fit for duty and specifically noted "no mental disorder." A note dated September 1978 reflects that the Veteran revealed a history of pre-service and in-service use of drugs. However, a mental status examination failed to reveal evidence of psychosis or disabling neurosis. The note reflects that he would be admitted to the Navy Drug Rehabilitation Center (NDRC) for evaluation and treatment. A doctor noted in October 1978 that the Veteran was on drugs (Valium and Belserene) that he did not want to give up and therefore needed detoxification. Later that month, a clinician at the NDRC noted that the Veteran reported taking a "copious amount" of tranquilizers prior to reporting to the NDRC and that he was unwilling to give up those substances or consider treatment alternatives. Even later in October 1978, a clinician at the NDRC stated that the Veteran's substance abuse problems were the result of his lifestyle choices rather than physical or psychological dependency. The Veteran's personnel file also reflects disciplinary problems, including non-judicial punishment and indicates his dependence on drugs. The Veteran did not receive a discharge examination and his discharge paperwork reflects that the Commanding Officer (CO) who recommended discharge stated that the Veteran had "intentionally concealed an extensive pre-service drug abuse history for the purpose of qualifying for enlistment." The CO observed that the Veteran reported using "marijuana, LSD, PCP, cocaine, hycodan, valium, darvon-N100, eskatrol, dexamyl, and belsiren continuously since age 16." Post-service, in October 1979, a VA physician noted that drug abuse did not appear to be his primary problem, observed "psychiatric symptoms of anxious and depression," and indicated that follow-up was needed to "R/O [rule out] schizoaffective illness." However, a psychiatric consultation note dated the same day as the physician's note reveals review of the Veteran and a psychiatrist's diagnosis of, only, drug-dependence. The Veteran was referred to a drug treatment program. The day following the VA psychiatric consultation, the Veteran was seen at a private hospital for feelings of anxiety. The treatment note observes that the Veteran reported using amphetamines for approximately one year and having been discharged from the military due to drug abuse. The diagnostic impressions were: paranoid character; drug abuse; and "R/O thought disorder." In November 1979, he was diagnosed with anxiety by a physician at that same hospital. VA treatment notes dated in 1980 and 1981 reflect treatment for diabetes as well as respiratory symptoms. A note dated in April 1982 reflects that the Veteran reported anxiety, depression, and insomnia; he requested valium. He again reported anxiety in March 1983 and February 1984; valium was prescribed. In February 1985 the Veteran again reported anxiety, nervousness, and insomnia; valium was prescribed. In April and July 1985 he reported anxiety and nervousness and, in December 1985, he complained of "feeling nervous" during the day; valium was prescribed again. Valium was also given after complaints of nervousness in February 1987, but xanax was prescribed in March 1987 and December 1986. Subsequent VA treatment records dating through the mid-1990s continue to reflect complaints of anxiety and difficulty sleeping treated with either valium or xanax. From November 1993 to January 1994, the Veteran was hospitalized at a VA facility for his psychiatric symptoms; a November 1993 referral note states that he was not psychotic at the time, but was being admitted secondary to an ex parte order. Although the discharge note states that he was treated at VA in 1978 and his symptoms improved with treatment, it also stated that his psychiatric history began in 1981 when he was treated for chemical dependency. The discharge summary also reveals that initial psychiatric testing did not indicate paranoid schizophrenic symptoms, but high levels of anxiety and depression, such that the diagnosis would be mixed personality disorder. However, at the time of discharge, the diagnoses were chronic paranoid schizophrenia and substance abuse. A January 1994 note specifically observes dependency on valium and codeine and attributes his anxiety to his physical problems, but also notes some paranoid ideation. In February 1994, a VA mental health consultation states that the hospitalization was for an adjustment disorder, but provisionally diagnosed a paranoid reaction, which was confirmed later that same month. In April 1994, another VA mental health consultation reflects diagnosis of major depression and the Veteran reported for treatment of feelings of depression in June 1994. An August 1994 VA treatment note reflects diagnosis of schizophrenia and depression as well as substance abuse. In September 1994, the Veteran was seen by a private physician for a psychiatric evaluation. The physician noted that the Veteran reported first experiencing psychiatric symptoms 20 years earlier. The report also states that, although the Veteran reported "heavy drinking and use of amphetamine and codeine," to include "really excessive abuse," he "evaded reporting length of time and termination dates" - the note indicates that the Veteran reported that he no longer abused substances. The physician diagnosed dysthymia and opined that he did not have "a major condition" and was not psychotic. An SSA physician completed a functional capacity assessment of the Veteran in October 1994 and concluded that he had chronic substance abuse, but was not psychotic although he did have some dysthymia. In November 1994, a VA physician noted that the Veteran had severe depressive episodes, but was not overtly psychotic. A January 1995 VA psychiatric treatment note again reflects diagnosis of schizophrenia and depression as well as substance abuse. In May 1995 another SSA evaluator completed a functional capacity assessment of the Veteran indicating that he had a personality disorder, but there was no evidence, from the Veteran's own history or his review of the medical record, supporting schizophrenia, but he did have polysubstance abuse. A VA psychiatrist noted in October 1995 that she first examined the Veteran in February 1994 and had last examined him in October 1995, for a total of 58 examinations. She explained that the Veteran reports for clinic visits, as well as attends the "long-acting clinic" and receives injections; it is not clear whether or not she was considering those visits as "examinations." Her assessment was of a "schizophrenic reaction, chronic paranoid type." Also in October 1995, the SSA determined that the Veteran had a "severe" impairment due to his schizophrenic reaction, paranoid type. The SSA determination stated that the Veteran had "been under" that disability since November 1993. The Veteran's SSA application reflects his contention that he "had chronic depression for years." In an August 2002 letter, the Veteran wrote to VA contending that he had experienced psychiatric symptoms prior to entry into active duty. Specifically, he reported having been treated for anxiety prior to service and experiencing additional anxiety while in-service due to his fears about life in the military - he specifically reported having been told stories about sodomy that he feared would happen to him. He further stated that he began making trips to Tijuana while in service in order to obtain "a Mexican version of Valium" to self-treat his anxiety. The Veteran wrote that he was eventually ordered into a drug treatment program and, during that program, realized that he had "some type of paranoia" rather than "a drug problem." He stated that he received continuous treatment, but his "paranoia and depression" continued to worsen until he was eventually, in late 1979, diagnosed with paranoid schizophrenia. The Veteran's treating VA psychiatrist submitted a statement in April 2004. She stated that the Veteran had a diagnosis of schizoaffective disorder requiring regular follow-up and medication to control symptoms such as paranoia, anxiety, and delusions. The psychiatrist opined that, although the Veteran's record showed abuse of benzodiazepines, his drug abuse was a "misguided attempt to self-medicate his underlying psychiatric illness." The psychiatrist stated that the Veteran's illness "most likely dated back to his military service period as evidenced by his many complaints of anxiety during that period." In August 2004, the Veteran wrote again to VA and contended that his disability began while he was on active duty. The Veteran was afforded a VA examination in June 2005. The examiner noted that the Veteran was in the Navy for seven months and was discharged with a general discharge under honorable conditions although he had enlisted fraudulently by giving incorrect information at the time of his enlistment. The Veteran informed the examiner that he had used drugs since his teenage years. The Veteran also reported that he first received psychiatric treatment at age 13 because his mother thought that he was "screwed up;" he reported taking thorazine at that time. Based on review of the record and interview with the Veteran, the examiner opined that the Veteran's psychiatric disorder most likely pre-dated military service and it was unlikely any current acquired psychiatric disorder was incurred in, or aggravated by, military service. The examiner identified the Veteran's diagnoses as schizoaffective disorder, alcohol dependence, and multi-substance abuse; all in full remission. VA treatment notes continue to reflect psychiatric care. A January 2006 social work note states that the Veteran reported having been denied service connection for "his psychiatric diagnosis for which he was also seen in the military." The social worker stated that she informed the Veteran that she would speak to his VA psychiatrist about writing a note to support his claim; although no subsequent letter appears in the record, the Board notes that the psychiatrist identified in the social work note was the same psychiatrist who wrote the April 2004 letter mentioned above. The Veteran was afforded another VA examination in May 2009. The report reflects that he also informed the 2009 examiner that he received his first psychiatric treatment at age 13, but did not take Thorazine although it was prescribed; he first used Valium and amphetamines and vicodin at age 23 and had also used cocaine, PCP, LSD. The Veteran reported anxiety, at times, minimal paranoia and intermittent depression. Examination revealed the Veteran was oriented, without delusions, but had preoccupation with one of two topics and had a rambling thought process with an overabundance of ideas and circumstantiality. The examiner diagnosed with schizoaffective disorder and opined that, although the Veteran had some form of disorder prior to service, the precise nature of that disorder was unclear. The examiner noted that he had prior drug abuse, but it was not clear if there was another disorder at that time and, even if there had been, it did not seem to be a psychotic process and was most likely an anxiety disorder or depressive disorder. The examiner observed that the Veteran was diagnosed with a schizoaffective disorder after service, but noted that diagnosis did not commence until several years after discharge. The examiner opined that, based on the findings and history, it was less likely than not that the current diagnosed psychiatric disorder had its onset in service and any opinion as to possible aggravation during service would require speculation - although the Veteran did report feeling increasingly anxious during service. Subsequently, the Board requested an expert medical opinion. In January 2011, a doctor of psychiatry reviewed the Veteran's medical and military records. She opined that it was less likely than not that the psychiatric symptoms documented within one year from the Veteran's separation from service were a manifestation of any current schizoaffective disorder as there were limited reports of psychosis, but those instances also referred to substance abuse. Specifically, she observed that, on one occasion, paranoia was noted in conjunction with an "LSD" flashback and, on another, delusional thinking was noted in conjunction with use of speed or Dexedrine; she noted that those substances could account for the symptoms and observed no mention of psychosis in the other records. The specialist opined that it is more likely than not that there have been manifestations of the Veteran's psychiatric disorder -substance abuse- continuously since service, but no evidence of an ongoing psychotic disorder as the Veteran worked as a security guard for 12 years and, in the expert's opinion, he would not have been able to maintain such employment if he had been psychotic. The specialist then opined that it was less likely than not that the Veteran's current diagnosis of schizoaffective disorder had its onset during service or was in any way causally related to his active service. The specialist stated there also was no indication that service had aggravated his condition since his condition seemed to progress naturally after service. Although noting the Veteran's report of pre-service anxiety and psychiatric treatment, the expert also noted reports of substance abuse before, during, and after military service. She again noted that two of the substances listed in the records could, by themselves, cause a long-term psychosis and mood disturbances and the Veteran had also used "speed," diet pills, and large quantities of caffeine that she stated could cause agitation, anxiety, and paranoia. The specialist noted that the Veteran's pre-service substance abuse may have been an attempt to self-medicate symptoms stemming from childhood abuse. A second specialist opinion was requested and received in June 2011. The examiner stated that there are no records pre-dating military service suggesting that any mental disorder, other than substance abuse, was present prior to military service. The specialist noted that service treatment records from March 1979, September 1978, and July 1978 indicated no psychosis, no psychiatric disturbances, and no neurosis and explained that, regardless, when psychotic and/or mood symptoms are present in the context of substance abuse, a psychiatric disorder (such as schizoaffective disorder) cannot be diagnosed because the impact of such substance abuse on mood and psychosis cannot be determined. The examiner opined that the Veteran did not enter service with a psychiatric disorder other than multiple substance use disorders; the examiner based that opinion on the absence of records thereof. The examiner then opined that the psychiatric symptoms documented within one year of serviced were not manifestations of his current schizoaffective disorder because they occurred when the Veteran was actively abusing drugs that could account for each of the symptoms reported. The specialist noted the opinion of the Veteran's treating psychiatrist from April 2004 - that the Veteran was likely using drugs to self-medicate underlying psychiatric illness - and stated that the rationale for her opinion was unclear as there was no evidence that psychiatric disturbance preceded substance abuse. Additionally, the expert observed that the 2004 psychiatrist stated the Veteran had many anxiety complaints during service, but per his service medical records did not reflect such complaints in the absence of substance abuse. A third expert opinion was requested in June 2013 to address more clearly whether or not any incident of active duty service had caused or aggravated any current mental disorder, in light of the Veteran's lay statements. The expert wrote a July 2013 opinion reflecting full review of the claims file, as indicated by a nine page, single spaced summary of the evidence therein. The expert commented on the evidence as different points in the chronology, observing that: at the time of his discharge, there was no evidence of any psychiatric illness other than drug dependence during his active duty service; during post-service treatment, the Veteran was prescribed some of the same drugs that he had abused, to include an amphetamine; chronic amphetamine use can lead to a paranoid psychotic reaction; pursuant to diagnostic criteria, paranoid schizophrenia and schizoaffective disorder cannot be diagnosed when there is underlying polysubstance abuse; and, in reference to the April 2004 letter from a VA psychiatrist, any opinion that he was using substances during service to self-medicate an underlying psychiatric problem could be based only on speculation since no psychiatric illness was noted on multiple service evaluations. On the basis of his review, as well as based on his clinical experience, the expert opined that the only psychiatric issue that might have predated the Veteran's service was polysubstance abuse and "some degree of anxiety that may have been precipitated by the polysubstance abuse." The expert stated that the answer to the question as to whether any psychiatric disorder clearly and unmistakably pre-existed service was no. The expert also opined that, as no disorder (other than substance abuse) had pre-existed service, no such disorder was aggravated by service; the expert also noted that only substance abuse was diagnosed in service. The expert further opined that no current psychiatric diagnosis, other than substance abuse, was incurred in or as a result of, aggravated by, or manifested within one year of, active duty service. The expert again explained that the Veteran's psychiatric symptoms, and post-service diagnoses, could "best be ascribed to chronic polysubstance abuse." In regard to the Veteran's lay statements as to having experienced anxiety and depression prior to service, the expert clarified that those are "symptoms, not disorders or DSM-IV diagnoses, just as pain is a symptom, not a disorder" and noted, regardless, that the Veteran was examined as normal at time of entry in spite of his self reports. In conclusion, the expert noted that the Veteran's pre-service, during service, and post-service polysubstance abuse was "apparently seamless" and there was no indication that it was exacerbated by service or continued by anything other than his own volition. Turning to the analysis of the case, the Board finds that the first element of service connection has been established as there is evidence of a current diagnosis. Since the Veteran's discharge from service, he has been given a multitude of difference diagnoses: drug dependence in October 1979; anxiety in November 1979; mixed personality disorder, chronic paranoid schizophrenia and substance abuse in January 1994; major depression in June 1994; schizophrenia and depression and substance abuse in August 1994; dysthymia in September 1994; polysubstance abuse in May 1995; schizophrenic reaction, chronic paranoid type in October 1995; schizoaffective disorder in April 2004; schizoaffective disorder, alcohol dependence, and multi-substance abuse, all in remission in June 2005; anxiety and depressive disorder in May 2009; schizoaffective disorder in January 2011; and chronic polysubstance abuse in June 2013. However, by law, there are certain disabilities for which service connection cannot be granted. As noted above, service connection for a substance abuse disability is precluded for purposes of all VA benefits for claims, such as the Veteran's, that were filed after October 31, 1990. VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (1999); see also VAOPGCPREC 2-98, 63 Fed. Reg. 31,263 (1998). Further, as the claims file contains some references to personality disorder, the Board also notes that pertinent regulation provides that a personality disorder is not a disease for compensation purposes. 38 C.F.R. §§ 3.303, 4.127. Accordingly, service connection for drug dependence, mixed personality disorder, substance abuse, alcohol dependence, multi-substance abuse, polysubstance abuse, and chronic polysubstance abuse must be denied as a matter of law. As such, the determination of the Veteran's claim hinges on whether any other psychiatric disability was incurred in, or as a result of - to include aggravated by - the Veteran's active duty service. Although the Veteran has contended to have a psychiatric disability that pre-existed his service and specifically identified that disability as anxiety and/or depression, the July 2013 expert explained that anxiety and depression are symptoms, rather than diagnoses. Moreover, 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). The presumption of soundness attaches where there has been an induction examination in which the later complained-of disability was not detected (Bagby, 1 Vet. App. at 227) and, here, the Veteran's March 1978 enlistment examination reflects no neurologic or psychiatric abnormalities despite the Veteran's contentions as to anxiety and depression. Although he also reported taking Darvon and Valium "occasionally" on an accompanying self report of medical history, a physician reviewed that note and commented those medications were used "very rarely for mild insomnia, not addicted." As only such conditions that are recorded in examination reports are considered to have been noted and any history of pre-service conditions recorded at the time of examination does not constitute a notation of such conditions, review of the Veteran's service records reflects no pre-existing psychiatric disorder noted such as would rebut the presumption of soundness. 38 C.F.R. § 3.304(b). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, there must be 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. Although the Veteran has contended, and some medical professionals - including two VA examiners - have indicated the possibility that, a psychiatric condition existed prior to service, that evidence does not rise to the level of clear and unmistakable evidence. In specific regard to the VA examiners' opinions, the Board observes that the 2005 examiner opined that a psychiatric disorder "most likely" pre-existed service, but was not aggravated thereby, and a 2009 examiner opined that the evidence was not clear as to whether a disorder other than substance abuse pre-dated service. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (stating that a physician's statement framed in terms such as "may," "could," or "possible" is not probative); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Bloom v. West, 12 Vet. App. 185 (1999). In contrast, multiple experts have opined, in more certain terms, that the Veteran did not have a pre-existing psychiatric disorder, other than substance abuse, and the claims file contains no medical evidence dated prior to service that shows a psychiatric diagnosis. As the record reflects that opinions have conflicted and does not contain any concurrent (to the time prior to service) medical evidence of psychiatric disability, there is not clear and unmistakable evidence of any such pre-existing disability. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). However, the Veteran has also contended that he is entitled to service connection for a psychiatric disorder that began during, or as a result of, his military service. In order to satisfy the second element of service connection, there must be a showing of in-service occurrence or aggravation of a disease or injury. Here, the Board has ruled out a pre-existing disability, so there need be no discussion on aggravation. As to in-service occurrence, the Board finds below that the probative evidence is against the claim and service connection is not warranted. The Veteran's service treatment records reflect that he experienced some drug-related symptoms during his active duty service. Although the competent medical evidence of record reflects that some of those symptoms continued after service, it contraindicates a finding that any such symptoms - in service or after service - led to his currently diagnosed psychiatric disorders. See 38 C.F.R. § 3.159(a)(1) (Competent medical evidence is: evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions; statements conveying sound medical principles found in medical treatises; and statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses). The in-service treatment notes specifically reflect repeated findings of no mental disorder other than substance abuse: July 1978 - no thought disorder, no mental disorder; September 1978 - no evidence of psychosis; October 1978 - substance abuse due to lifestyle choices, based on the Veteran's unwillingness to give up the drugs he took or consider treatment alternatives. Based upon these records alone, there is no indication of a psychiatric disability in service. Although the Veteran claims otherwise, and has contended that his in-service drug use was self-treatment of service-related anxiety, the contemporaneous service treatment records show that he used the same drugs prior to service and that he was examined several times while on active duty and was found not to have a mental disability. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than subsequently reported history). As such, there is no evidence, other than the Veteran's unsupported assertions, of any in-service incurrence of a psychiatric disability. The medical evidence of record generated after the Veteran's discharge from service continues to reflect symptoms attributed to substance abuse, rather than any acquired psychiatric disorder. Specifically, as noted above, within one year of the Veteran's discharge from service, a VA physician, in October 1979, attributed the Veteran's symptoms of anxiety and depression to an underlying psychiatric disability rather than substance abuse, but that same physician ordered a psychiatric consultation that resulted in diagnosis of only drug-dependence. Although the Veteran was diagnosed with anxiety and paranoid character later in 1979, as well as anxiety, depression, and insomnia in the 1980s, these records, as well as the service records, were analyzed by experts in June 2011 and July 2013 who determined that they did not represent psychiatric symptoms, but manifestations of drug abuse. Their opinions, as well as the medical evidence detailed above, reflect that the Veteran was not definitively diagnosed with psychiatric disability in addition to substance abuse until 1994. The Board has considered the medical evidence as to the symptoms occurring after the Veteran's discharge from active duty as well as the Veteran's own lay statements that his mental disorder is related to, and has continued since, his military service since 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). However, as explained immediately above, the symptoms occurring over the more than ten year period immediately following the Veteran's discharge have been attributed to symptoms of substance abuse, for which service connection cannot be granted. Although the Veteran has contended that his symptoms were manifestations of psychiatric disability rather than substance abuse, and 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). Moreover, the Board finds that he, as a lay person, is not competent to render an etiological opinion in this particular instance because the question of etiology of a psychiatric disorder - which, here, requires distinguishing between the effects of chemical substances on the brain and the behavioral effects of psychiatric disorders - involves a medical subject concerning internal 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 v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds that there is no showing of any chronic psychosis (i.e. schizo-affective disorder) in service, or continuously therefrom, as to satisfy 38 C.F.R. § 3.303 (b); the Veteran cannot support his claim on the basis of his own assertions of continuity of symptomatology, alone. See Walker, 708 F.3d 1331. Moreover, although some clinicians noted that the Veteran may have experienced psychiatric symptoms prior to service and an April 2004 VA psychiatrist opined that the Veteran's in-service substance abuse was a "misguided attempt to self-medicate his underlying psychiatric illness," the Board, above, determined that the presumption of soundness remains intact. Further, a June 2005 VA examiner opined that it was unlikely any current acquired psychiatric disorder was incurred in, or aggravated by, military service and a 2009 examiner noted that psychiatric diagnosis of schizoaffective disorder did not occur until many years after service. These examiners based their opinions on interview and examination of the Veteran as well as review of the record. The experts who wrote opinions in January and June 2011 as well as July 2013 wrote similar reviews of the medical evidence of record, opining, based on their clinical expertise and review of the record, that psychiatric disability other than substance abuse did not occur until years after service. Specifically, the January 2011 expert noted that the Veteran's drug abuse could account for his psychiatric symptoms during and shortly after service and his employment history contraindicated the existence of any psychosis. The June 2011 expert opined that the psychiatric symptoms documented within one year of service were not manifestations of his current schizoaffective disorder because they occurred when the Veteran was actively abusing drugs that could account for each of the symptoms reported. The 2013 expert also opined that no current psychiatric diagnosis, other than substance abuse, was incurred in or as a result of, aggravated by, or manifested within one year of, active duty service and explained that the Veteran's psychiatric symptoms, and post-service diagnoses, could "best be ascribed to chronic polysubstance abuse." In evaluating the evidence of record, the Board places great probative weight on the expert opinions regarding the etiology of the Veteran's psychiatric disorder 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). When faced with conflicting medical opinions, the Board must weigh the credibility and probative value of each of the opinions, and in so doing, the Board may favor one - or, in this case, multiple - medical opinion(s) over the other(s). See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez, supra. Initially, the Board will assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. Second, the Board will consider whether or not the medical expert provided a fully articulated opinion. Id. Finally, the Board considers whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez, supra; Stefl, supra. Here, only the VA experts reviewed the entire claims file (as some evidence was added after the conduct of the VA examinations), but the Board notes that review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a Veteran, as had the October 1979 VA physician (who noted symptoms of anxiety and depression) and the Veteran's subsequent VA psychiatrist (who authored the April 2004 letter). Id. at 303-04. However, here, it does not appear as though the VA psychiatrist was fully informed of pertinent factual premises as it does not reflect awareness of the normal enlistment examination and incorrectly refers to "many [in-service] complaints of anxiety." Second, the VA psychiatrist did not provide a fully articulated opinion as she did not discuss the possible pre-service existence, and in-service aggravation, of a psychiatric disorder. In contrast, the experts discussed the possibility of aggravation of a pre-service disorder as well as in-service (to include within one year of service) incurrence of a psychiatric disorder, and analyzed the nature of the current psychiatric diagnoses in relationship to the treatment history. The experts also provided in-depth analyses of the evidence and medical reasoning discussing the effects of substance use/abuse whereas the VA psychiatrist only notes use of chemicals and does not describe their effects on behavior and thought process. See Nieves-Rodriguez, supra; Stefl, supra. In specific regard to the 1979 VA physician's observation of anxiety and depression, the 2013 expert clarified that those are symptoms, not psychiatric disabilities. Further, each of the experts, as well as a 1979 consulting psychiatrist, attributed those symptoms to drug use. For these reasons, the Board finds the opinions of the experts most probative. Evans, 12 Vet. App. at 30; Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999). Thus, the most probative evidence of record is against the claim and service connection cannot be granted. 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 Entitlement to service connection for an acquired psychiatric disorder is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs