Citation Nr: 1334097 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 10-15 184 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include dysthymic disorder and posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD Christopher McEntee, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to March 1966. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA). In October 2001, the Veteran filed an original claim to service connection for a psychiatric disorder (nervous condition). In a September 2002 rating decision, the RO denied his claim. The Veteran appealed that decision to the Board. In May 2005, the Board remanded the claim for additional development. Subsequently, in a in a February 2007 decision, the Board denied the Veteran's claim. As the Veteran did not appeal the decision, the February 2007 Board decision became final. 38 C.F.R. § 20.1100. In February 2009, the Veteran filed a claim to reopen service connection for a psychiatric disorder. In the March 2009 rating decision on appeal, the RO denied the claim. In November 2010, the Board reopened and denied the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2011 Order, the Court granted the parties' Joint Motion, vacating in part the Board's November 2010 decision and remanding the claim of entitlement to service connection for an acquired psychiatric disorder for compliance with the terms of the Joint Motion. In response, in October 2011 and May 2012, the Board remanded this appeal for additional development and medical inquiry. In December 2012, moreover, the Board obtained a medical opinion from a psychiatrist with the Veterans Health Administration (VHA). The case is again before the Board for appellate review. In statements of record, the Veteran has described his incurred psychiatric disorder as a nervous disorder, or as a neuropsychiatric disorder. Private treatment records and reports note diagnoses of depression and PTSD. Meanwhile, VA treatment records and reports note diagnoses of dysthymia, depressive disorder, and bipolar disorder. As such, the Veteran's claim has been characterized generally, as one of service connection for a an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (a claim for a mental health disability includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Board will therefore consider whether a service connection finding is warranted for any diagnosed psychiatric disability. The Board notes that it has reviewed the Veteran's entire claims file, to include documents of record in his virtual VA folder. The Veteran has submitted additional relevant information since the most recent supplemental statement of the case (SSOC) dated in October 2012. This information has been considered pursuant to the Veteran's October 2012 waiver of initial review of the evidence by the Agency of Original Jurisdiction (AOJ). 38 C.F.R. §§ 19.31, 20.1304(c) (2013). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has an acquired psychiatric disability that is etiologically related to a disease, injury, or event in service. CONCLUSION OF LAW A psychiatric disorder was not incurred in or aggravated by active service, and may not be presumed related to service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA must provide notice and assistance to claimants for VA benefits. 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 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 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 notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Veteran was provided with satisfactory notice in VCAA letters of record dated in February 2009 and October 2011. The letters informed the Veteran of the evidence and information necessary to substantiate his claim for service connection, and informed the Veteran regarding his and VA's respective responsibilities in obtaining evidence and information. The letters also informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date. Though full notification was not provided to the Veteran prior to the rating decision on appeal, the timing error has been corrected by the readjudication of the claim in the April and October 2012 SSOCs. Overton v. Nicholson, 20 Vet. App. 427, 437 (2006). With regard to VA's duty to assist, the record indicates that in the notification letter, VA requested from the Veteran information regarding medical evidence pertaining to his claim for service connection. The record shows that the RO included in the claims file the Veteran's service treatment records (STRs), records from the Social Security Administration (SSA), and relevant private and VA treatment records and reports. Furthermore, the Veteran has undergone two VA compensation examinations into his claim, in August 2003 and November 2011. As noted in the October 2011 remand, certain inadequacies were noted with the August 2003 examination report. The shortcomings were addressed in the November 2011 examination and January 2012 report of examination. Further, as indicated earlier, the Board sought and obtained additional medical evaluation of the Veteran's claim in the form of a VHA opinion completed in December 2012. Combined, the three reports detail the nature of the Veteran's psychiatric disability, indicate a review of the claims file, and note findings based on the Veteran's lay statements, on the evidence of record, and on the examination of the Veteran. The findings are supported by data and reasoned explanations, moreover. 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"). These reports, together, satisfy the duty to assist. In sum, the Board finds that VA's duties to notify and assist have been substantially met. II. The Claim to Service Connection The Veteran claims service connection for a psychiatric disorder. He contends that he developed a psychiatric disability due to verbal abuse and mistreatment he claims to have experienced during his slightly over 2-month enlistment. For example, he states that he was traumatized by having to mop a floor with a heavy mop during training despite the fact that he then had a fever and thinking he was being sent for medical care. He also attests to being traumatized by his early discharge from service just after completing basic training. He states that the discharge was due to his difficulty with the English language. He reports that he became very depressed after being discharged from the Army and that he continues to suffer from recurrent depression to the present day. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The U.S. Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in § 3.303(b) is limited to chronic diseases found in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 C.F.R. § 3.309(a), psychosis is considered a chronic disease. In the absence of presumptive service connection, to establish a right to compensation for a present disability on a direct basis, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In assessing claims for service connection, the Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses). Lay evidence may also be competent to establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F. 3d at 1377. Also, a veteran as a layman is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; he or she is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Once competency is established, as a fact finder, the Board is also obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F. 3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In this matter, the preponderance of the evidence establishes that the Veteran has a current acquired psychiatric disorder. Private and VA treatment records and reports dated since the early 2000s consistently note diagnoses of dysthymic disorder and depressive disorder. Furthermore, in February 2009, a VA treatment record noted a diagnosis of bipolar disorder. The first element of Shedden is established here, therefore. The preponderance of the evidence establishes, however, that the Veteran does not have PTSD, and certainly has not been diagnosed with PTSD during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim"). Although a private physician diagnosed the Veteran with PTSD in August 2001 - prior to February 2009 claim on appeal - the bulk of the evidence, both lay and medical, indicates that the Veteran has never had PTSD. None of the private or VA medical evidence dated before the August 2001 private report notes a diagnosis of PTSD. None of the private or VA medical evidence dated since the August 2001 private report notes a diagnosis of PTSD. The August 2003 VA report expressly found that the Veteran did not have PTSD. VA treatment records dated between 2001 and 2012 do not note a diagnosis of PTSD. VA treatment records dated in March 2006, February 2007, and February 2009 detail negative PTSD screenings based on interviews of the Veteran. A February 2009 letter from a private physician, which notes depression and dysthymia, does not contain a PTSD diagnosis. In the January 2012 VA report, the November 2011 VA examiner states that the Veteran does not have PTSD. The December 2012 VHA examiner - after indicating a review of the claims file and after detailing the Veteran's history of psychiatric complaints and treatment - expressly found that the Veteran did not have PTSD. As with the August 2003 and January 2012 VA reports, the VHA report concluded with a finding that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. The VHA examiner also, in assessing the value of the August 2001 private report, questioned the accuracy of the PTSD diagnosis because "there is no formal mental status examination given" and the PTSD diagnosis did not have "supporting DSM-IV criteria detailed in the evaluation; in particular, the diagnosis of PTSD does not have a credible stressor indicated." Finally, in a March 2013 letter noting depression, the private physician who noted a diagnosis of PTSD in August 2001 appeared to undermine that PTSD diagnosis by omitting a PTSD diagnosis from the March 2013 report. Moreover, a review of the Veteran's many statements of record since 2001 indicates that he never asserted clearly that he has PTSD. He repeatedly indicated from 2001 to 2009 that he incurred a "nervous condition" and a "n/p" (neuropsychiatric) disorder during service. Then, in his April 2009 notice of disagreement (NOD), he stated that he disagreed with the RO's denial of service connection for "n/p including PTSD (however diagnosed)." But this is not a clear assertion to having PTSD. Indeed, in none of his statements, to include a "stressor statement" he submitted into evidence in November 2011, does the Veteran state clearly that he believes he experienced a stressor in service that caused the development of PTSD. Rather, his statements indicate an interest in service connection for a nervous disorder, or a neuropsychiatric disorder. Thus, despite the sole diagnosis of PTSD in August 2001, the bulk of the evidence of record indicates that the Veteran does not have PTSD - that he does not meet the DSM-IV criteria for a diagnosis of PTSD during any period of his appeal (as required by VA regulations). Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). An inquiry into whether PTSD is related to service is therefore unwarranted. However, as indicated earlier, the first Shedden element has been established by the evidence of record indicating diagnoses during the appeal period of dysthymic, depression, and bipolar disorders. As to the second Shedden element - whether the Veteran experienced an in-service emotional or psychiatric injury - the Board finds the evidence of record in equipoise. See Gilbert, supra. On the one hand, certain evidence of record indicates that the Veteran did not have a psychiatric or emotional injury during service. The Veteran's STRs are negative for a psychiatric disorder. The March 1966 separation report of medical examination indicated a normal psychiatric clinical evaluation. In his March 1966 separation report of medical history, the Veteran expressly denied having nervousness, nightmares, and/or trouble sleeping. The earliest evidence of record addressing a psychiatric disorder is found in a SSA record dated in July 1988. The record indicates a "nervous condition" but does not mention the Veteran's service at all. Further, the record is dated over 20 years after the Veteran's discharge from active service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability may be considered in evaluating a claim of service connection). On the other hand, the Veteran has submitted several lay statements of record attesting to the distress he experienced during service. The crux of his claim is that he was emotionally injured because of the way he was treated during boot camp (i.e., forced to work despite having a fever), because of his difficulty during service with the English language, and because of his discharge from service just two months after his enlistment. His statements regarding his feelings of distress, disappointment, dismay, and resentment in 1966 are of probative value because his feelings are observable symptomatology, and are therefore capable of lay observation. Hence, though the record contains no evidence dated during service which indicates in-service distress, the Board will accept the Veteran's lay statements as evidence that he did in fact experience emotional upset during service. See Layno and Shedden, both supra. Nevertheless, service connection for an acquired psychiatric disorder is unwarranted here because the third Shedden element is not established by the record - the preponderance of the evidence indicates that the Veteran's in-service distress is unrelated to the psychiatric problems diagnosed during the appeal period. Moreover, a presumptive service connection finding would be unwarranted because the evidence does not indicate that the Veteran developed psychosis within one year of his 1966 discharge from active duty. 38 C.F.R. §§ 3.303, 3.307, 3.309. In addition to the Veteran's lay statements regarding the etiology of his current psychiatric problems, there are five medical opinions of record which address his claim. Two private opinions of record support the Veteran's claim while three VA opinions counter his claim. The first of the favorable private opinions is found in the August 2001 report. That examiner recounted the Veteran's complaints of in-service distress. He reported that the Veteran stated that he experienced psychiatric pain following service and felt "incompetent" and "inadequate" because of the early discharge due to his difficulty with English. The examiner described the Veteran's claim that he attempted suicide due to the distress, that he developed alcoholism due to the distress, and that he experienced a catastrophic industrial injury in 1972 resulting in grave injuries to his upper extremities due to the distress. He indicated that he suffered the loss of both hands in the accident, had a metal hook on his left hand, and lost most of the fingers on his right hand. The examiner stated that the accident "probably subconscious, was a suicide attempt" by the Veteran so that he could avoid taking an English examination related to the civilian employment. The examiner indicated that the test created stress because it reminded the Veteran of his troubles during service. This examiner found PTSD, chronic dysthymic disorder, and probable recurrent major depression due to service because the Veteran's "premature discharge" from the army caused him "grave damage." The Board notes that this same examiner submitted a March 2013 report into the record which notes a diagnosis of depression. The March 2013 report does not contain an opinion addressing the issue of medical nexus, however. The second favorable opinion is found in the February 2009 report. This physician stated that the Veteran's past medical history included a diagnosis of major depression. She stated that the Veteran presented with depressed mood, insomnia, and marked decrease in pleasure in most activities. She also noted that he was treated by a psychiatrist and that he was taking medications. Based on the Veteran's reported history, the physician reiterated that the Veteran was "retired from service immediately after completing basic training because he did not know how to speak English." He reported feeling very depressed because of this rejection and that he suffers from obsessive, ruminating thoughts about the cause of his discharge from service. The physician concluded that it was more probable than not that the Veteran's chronic dysthymic disorder was caused by "an event or experience in-service." She also opined that it was more probable than not that a relationship between the Veteran's current symptoms and complaints of his premature discharge from the Army exists. The first of the medical opinions countering the Veteran's claim is found in the August 2003 VA report. In the report, the examiner indicated an examination of the Veteran, indicated a review of the claims file, and detailed the Veteran's medical history, to include his complaints of in-service distress, his complaint of post-service psychiatric difficulties, and the challenges he faces due to the industrial accident. After finding that the Veteran did not meet any the diagnostic criteria necessary for PTSD - the examiner stated that the Veteran denied experiencing a traumatic event in-service - the August 2003 examiner diagnosed the Veteran with dysthymia. The examiner further stated that the Veteran's symptomatology (i.e., depression/dysthymia) had no relationship to service. The January 2012 VA report (based on the November 2011 examination) contains the second negative opinion. This examiner, the same examiner who conducted the August 2003 VA examination, noted that she again examined the Veteran, noted that she reviewed the claims file, and again detailed the Veteran's medical history in the report. As she did in the August 2003 report, this examiner, after extensive testing, found the Veteran without PTSD. Unlike the August 2003 report, in which a dysthymic disorder was noted, the examiner in the January 2012 report also found the Veteran to be without any other psychiatric disorder. Indeed, she stated that the Veteran showed no "symptoms compatible with any mental disorder." The Board finds significant weaknesses with each of these four opinions. The two private opinions are of limited probative value because each is entirely based on the history provided by the Veteran. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Indeed, neither private report indicates a review of the claims file. Significantly, moreover, neither private report discusses the absence of evidence of a psychiatric disorder following service until the July 1988 SSA record noting a nervous condition. See Maxson, supra. The Board also finds significant weaknesses with regard to the August 2003 and January 2012 VA opinions. As noted by the Joint Motion remand, the August 2003 report was written years prior to the Veteran's February 2009 claim on appeal. Thus, while it is of probative value regarding the Veteran's mental state in 2003, it is not of much value regarding the current appeal period, particularly give the fact that so much additional evidence has been added to the record since 2003. Further, the January 2012 opinion is of limited probative value because it does not contain a medical nexus opinion regarding the disorders diagnosed during the appeal period - dysthymia, depression, and bipolar disorder. See McClain, supra. By contrast, the Board finds the December 2012 VHA opinion to be of significant probative value. The examiner is a psychiatrist and is the Chief of the Department of Psychiatry of the VA Greater Los Angeles Healthcare System. In his report, he indicated a comprehensive review of the claims file, detailed the Veteran's history, entered findings based on clinical data, and explained his findings. Bloom v. West, 12 Vet. App. 185, 187 (1999). After reviewing the Veteran's medical history, the examiner thoroughly addressed the four nexus opinions noted earlier. In particular, he noted weaknesses with the supportive private reports. For example, he noted that the August 2001 report was not based on a formal mental status examination, and noted that the February 2009 report did not discuss the Veteran's 1972 industrial accident and what effect, if any, that trauma had on the Veteran's mental state. In his conclusion, the VHA examiner questioned the diagnoses of record of PTSD and bipolar disorder. He stated that DSM-IV criteria for PTSD was not met. He stated that there was only a history of manic symptoms in the claims file, and not any "clinical manifestations of such symptoms." He found that the Veteran's "many years of medical records" were devoid of evidence of Bipolar Disorder. He therefore found that the Veteran did not have PTSD or Bipolar Disorder. The examiner stated that the record fully supported diagnoses of depressive disorder and dysthymia, "variously referred to as Bipolar Disorder Type II depressed, Dysthymic Disorder, Major Depression, and Depressive Disorder Not Otherwise Specified." As to the issue of medical nexus, the examiner stated that the record lacked "objective evidence that the Veteran had any lasting physical illness stemming" from his service. Further, the examiner found no evidence of onset of a psychiatric disease in the 5.5 years following service, prior to the catastrophic industrial accident that resulted in amputation of much of his upper extremities. The examiner also cited the "first apparent psychiatric contact" many years following discharge from service. The examiner then found "no appreciable connection between the Veteran's military service and his long-standing Dysthymia." In summary, the two private medical opinions supporting the Veteran's claim to medical nexus are of limited probative value because they are based on the Veteran's own reported history rather than on clinical data. The August 2003 VA opinion is of some probative value but its weight is significantly limited by the fact that it was rendered several years prior to the claim on appeal. The January 2012 VA opinion is also of probative value to the extent it addresses whether the Veteran has PTSD - but it is not probative in the matter before the Board because it did not offer a medical opinion regarding whether a dysthymic disorder, or a depressive disorder, relates to service. The upshot is that the supportive nexus evidence in the two private opinions does not outweigh the negative evidence in the two VA opinions, or vice versa. The decisive evidence in this matter is found in the VHA report which, as detailed earlier, comprehensively addresses the Veteran's claim and clearly provides an opinion regarding etiology. See Bloom, supra. As such, the Board has placed great weight on this medical opinion. On the issue of medical nexus - the third Shedden element - the Board has considered the Veteran's lay assertions that his psychiatric disorder is due to the distress and disappointment he experienced during service. As indicated earlier, the Veteran may be competent to testify regarding symptoms which are observable, such as the feelings he experienced in 1966 and after service. However, his assertion regarding the positive causal relationship between his feelings of disappointment in 1966 and the diagnosed psychiatric disorders during the appeal period is of limited probative value because he is not competent to render such a determination. The disorders at issue here - acquired psychiatric disorders - involve an internal pathology of the brain and psyche, which is beyond his capacity for lay observation. The etiology and development of his psychiatric problems cannot be determined through observation or by sensation such as feeling. The Veteran is simply not competent to render a medical opinion regarding the way in which his disorders developed. He does not have the training and expertise to provide medical evidence connecting service to his symptoms, or connecting the symptoms to the psychiatric disorder at issue. The Veteran cannot provide evidence that states that what he experienced during service, or has felt since service, resulted in dysthymia or depression. On this essentially medical question, the Veteran's statements are not probative. As such, the Board places limited weight on the Veteran's lay assertions regarding the issue of etiology, particularly in comparison to the comprehensive December 2012 VHA opinion. The record establishes that the Veteran has an acquired psychiatric disorder. However, the preponderance of the evidence of record demonstrates that service connection is not warranted here. The supportive private reports, in addition to the two VA reports, are of limited probative value with regard to the question of whether the Veteran's current disorders relate to his in-service distress. By contrast, the Board has assigned great weight to the December 2012 VHA report, which indicates that the Veteran did not incur his psychiatric problems during service, or within one year of his 1966 discharge from service. On these particularly complex medical issues, the VHA opinion clearly outweighs the two private opinions and the lay assertions on which they are based. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for an acquired psychiatric disorder is denied. ____________________________________________ N. RIPPEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs