Citation Nr: 1334415 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 04-39 884 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a left ankle disability. 3. Entitlement to service connection for acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, and schizoaffective disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The Veteran had active duty service from June 1975 to November 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). These matters were remanded in March 2008, September 2010, June 2012, and June 2013 for additional development. FINDINGS OF FACT 1. A chronic left knee disability was not manifested during the Veteran's active duty service or for many years thereafter, nor is a chronic left knee disability otherwise causally related to service. 2. A chronic left ankle disability was not manifested during the Veteran's active duty service or for many years thereafter, nor is a chronic left ankle disability otherwise causally related to service. 3. The Veteran does not have a diagnosis of PTSD in accordance with DSM-IV based on a corroborated stressor event in service or based on a fear or hostile military or terrorist activity; a chronic psychiatric disability was not manifested in service; a psychosis was not manifested within one year after the Veteran's separation from service; and no diagnosed psychiatric disability is shown to be related to his service. CONCLUSIONS OF LAW 1. A chronic left knee disability was not incurred in or caused by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). 2. A chronic left ankle disability was not incurred in or caused by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). 3. A chronic acquired psychiatric disability was not incurred in or caused by the Veteran's active duty service, nor may it be presumed to have been incurred in such service. 38 U.S.C.A. §§ 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). By December 2003, October 2005, April 2008, September 2010, and June 2012 letters, the Veteran was informed of the information and evidence necessary to warrant entitlement to the benefits sought on appeal and was also advised of the types of evidence VA would assist him in obtaining as well as his own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). These letters also informed the Veteran of disability rating and effective date criteria. In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist The VCAA also provides that VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Veteran's service treatment records (STRs), service personnel records (SPRs), VA and private treatment records are associated with the claims file and the Veteran has not identified any pertinent evidence that remains outstanding. The RO arranged for VA examinations in June 2006 (with a July 2006 addendum opinion), November 2009, and June 2013. The examinations were adequate as the examiners considered the evidence of record and the reported history of the Veteran, conducted thorough examinations of the Veteran, noting all findings necessary for proper adjudication of the matters, and explained the rationale for the opinions offered. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues on appeal. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. B. Legal Criteria, Factual Background, and Analysis Service connection Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). 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). Certain chronic disabilities, such as arthritis and psychosis, 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. Left knee disability The Veteran's STRs reflect that he was seen in October 1975 for intermittent knee pain and was diagnosed with mild chondromalacia; X-rays at that time showed no significant abnormality. A December 1977 medical condition-physical profile record indicated that the Veteran had chondromalacia patella. On September 1978 service separation examination, no residuals of the left knee injury were noted, and the lower extremities were normal on clinical evaluation. In a contemporaneous report of medical history, the Veteran checked the appropriate boxes to deny any bone, joint or other deformity as well as "trick" or locked knee; he did not indicate that he had any knee disability. On April 1981 VA examination, the Veteran reported that both knees were injured in 1974 when he fell off the top of a tank while he was removing some cables; he reported that both knees were bruised badly and there were no fractures or dislocations involved. He complained that his knee would still become sore if he sat for very long. The diagnoses included left knee trauma by history only, with entirely normal range of motion; no swelling, deformation or redness; and a radiological examination was equally negative. On March and December 2006 VA treatment, the Veteran complained of chronic knee pain. A January 2007 X-ray of the left knee was negative for any findings, including any degenerative joint disease. On October 2009 VA treatment, the Veteran reported that his knee had twisted 10 days earlier and he was experience knee pain and instability. On July 2011 treatment, the Veteran reported limited mobility due to chronic knee pain. On December 2011 VA treatment, the Veteran reported knee pain of 7/10 severity while witting without a brace, which increased if a brace was applied, and pain of 9/10 severity when walking. April 2012 X-rays of the left knee showed mild degenerative joint disease. In a June 2013 decision, the Board reopened the previously denied claim for service connection for left knee disability and remanded the matter to obtain outstanding treatment records and afford the Veteran a VA examination and nexus opinion. On June 2013 VA examination, the examiner noted the October 1975 and December 1977 STRs showing a diagnosis of chondromalacia patella, the 1978 separation examination showing the Veteran's lower extremities to be clinically normal, the April 1981 VA examination cited above, October 2009 VA treatment noting a twisted left knee 10 days earlier, and July 2010 VA treatment noting left knee pain. On examination, the Veteran reported pain in both knees, the right knee being much worse than the left. He recalled having some pain in the left knee while in service which was not that bad, but it worsened in the winter after he left service; he believed that his left knee became much worse in the 1990s and made it more difficult for him to walk. He reported pain of 5-6/10 severity in the left knee, and he stated that the left knee does not give way. He reported that he regularly used a scooter as he had difficulty walking every day due to his knees and ankles, mostly his right knee and right ankle. The diagnosis was degenerative joint disease of both knees. The June 2013 VA examiner opined that it is less likely as not (less than 50 percent or higher degree of probability) that the current left knee degenerative joint disease is causally related to his service, to specifically include any left knee symptoms during service. The examiner noted that the Veteran does have documentation of left knee chondromalacia patella in service as well as evidence now of left knee pain with mild degenerative joint disease. However, the examiner opined that there is no good nexus to connect the two, noting that the Veteran was denied service connection in 1981 after an examination showed a normal left knee as well as a normal right knee. The examiner opined that the in-service knee condition likely resolved as was noted in the 1981 post-service examination. The examiner opined that the Veteran's current left knee problems are more likely due to the natural aging process. Additional VA treatment records through 2013 further document the Veteran's complaints of pain and other symptoms of the left knee without otherwise presenting any pertinent etiological information or further detail concerning pertinent history. The Board finds that the contemporaneous STRs presenting competent medical findings and the Veteran's own symptom reports are highly probative evidence concerning that period. The Board finds that these records reflect that the Veteran was diagnosed with mild chondromalacia patella in service and that X-rays at that time showed no significant abnormality, and that no left knee disability was noted on his service separation examination. There is no contemporaneous evidence of symptoms or treatment concerning any left knee disability for more than 27 years following service (from separation in November 1978, to the first treatment record for pain of the left knee in March 2006). The June 2013 VA examiner clearly concluded that the Veteran's current left knee disability is not caused by or a result of his military service. The Board finds that the June 2013 VA examination report is highly probative in this case. The report (which is found to be adequate) contains competent medical opinions addressing the pertinent etiological questions with clear conclusions and analytical rationales; it is informed by review of the claims file, interview of the Veteran, and direct medical inspection of the Veteran's left knee disability. The Board has reviewed the entirety of the evidence of record but finds that there is no persuasive evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the matter of a left knee disability. The Board acknowledges that the claims file contains a quantity of other medical records, but none of the information in these records pertinently contradicts the conclusions or cited rationales of the evidence found to be most probative in the discussion above. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Here, the Veteran did not have documented reported symptoms of the left knee at the time of his separation from service. The lower extremities were evaluated by military medical personnel as clinically normal. This suggests that it was the opinion of the medical examiners that no knee abnormalities were detected. It is also significant that there is no persuasive evidence of the claimed left knee disability for many years following service. The Veteran has been afforded a VA examination in connection with his claim; the examiner provided negative nexus opinions. The June 2013 VA examiner provided persuasive rationale discussed above that addressed the Veteran's in-service injury history, his post-service injury history, and the significance of his specific knee symptom history and clinical findings. To the extent that the Veteran's statements suggest a continuity of lay-perceivable symptoms after his alleged in-service injury, such assertions are inconsistent with the discharge examination report which shows that he denied knee problems and that medical examiners found his lower extremities to be clinically normal. Such statements made many years after the fact are of diminished credibility when viewed against the discharge examination findings. The Veteran has clearly received treatment for the claimed left knee disability since 2006, but this appears to have begun approximately 28 years after service; the Veteran's own reports consistently place the onset of his symptoms several years after his separation from service. The post-service medical records do not reflect any continuity of symptomatology, medical treatment, or other manner of perception of pain or pathology of the left knee in the years proximately following service. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claims. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Given the facts that (1) the STRs do not diagnose any chronic claimed disability, (2) the first evidence of any chronic claimed knee disability is not shown until at least 27 years after service, and (3) the medical evidence of record fails to relate any currently existing claimed knee disability to active service, the Board finds that the Veteran's statements are afforded low probative value as to the onset and etiology of his current chronic left knee disability. In sum, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim. As such, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for left knee disability is denied. See 38 U.S.C.A § 5107. Left ankle disability The Veteran's STRs indicate that the Veteran was taken to the emergency room for a sprained ankle, as reflected in an undated STR. March 1976 X-rays of the left ankle showed severe swelling of the soft tissues around the lateral malleolus and there was otherwise no evidence of any bone traumatic abnormality. He was placed on temporary profile for 7 days. On September 1978 service separation examination, the Veteran's feet and lower extremities were normal on clinical evaluation. In a contemporaneous report of medical history, the Veteran checked the appropriate boxes to deny any bone, joint or other deformity or any foot trouble, and he did not report any left ankle disability. On April 1981 VA examination, the Veteran reported that he injured his left ankle in 1975 during physical training when he fell into a ditch, suffering a bad sprain only at the time, with no fracture or dislocation. He reported that the left ankle had not given him any further trouble since then. On physical examination, no current left ankle disability was found. The diagnoses included left ankle trauma by history, with no evidence of impairment. On March 2010 VA treatment, the Veteran complained of left ankle pain. He reported episodes of twisting and pain as recently as two months earlier. He had not had any surgery, injections, braces, or physical therapy. He wore high top diabetic shoes which helped. The assessment was right ankle recurrent sprains. On May 2012 VA treatment, the Veteran complained of pain to palpation to the anterior left ankle with dorsiflexion and plantar flexion. X-ray results showed no definite acute findings of the left ankle. In a June 2013 decision, the Board reopened the previously denied claim for service connection for left ankle disability and remanded the matter to obtain outstanding treatment records and afford the Veteran a VA examination and nexus opinion. On June 2013 VA examination, the examiner noted the STRs showing a sprained ankle and March 1976 X-rays showing severe swelling of the soft tissues but no deformity of the ankle, and March 2010 VA treatment noting left ankle pain. On examination, the Veteran reported that he injured the left ankle in service, and he complained of ankle pain in the winter which began to bother him after service. He reported ankle pain with cold weather or walking, and he reported that the left ankle would give way sometimes. He reported that he regularly used a scooter as he had difficulty walking every day due to his knees and ankles, mostly his right knee and right ankle. The diagnosis was bilateral ankle strain. The examiner opined that it is less likely as not (less than 50 percent or higher degree of probability) that the Veteran's current left ankle sprain is causally related to his service, to specifically include any left ankle symptoms during service. The examiner noted that the Veteran does have documentation of a left ankle sprain in service as well as evidence now of left ankle pain with chronic strain. However, the examiner found that there is no good nexus to connect the two, noting that the Veteran was denied service connection in 1981 after an examination showed a normal left ankle. The examiner opined that the in-service left ankle sprain likely resolved as noted in the 1981 post-service examination. The examiner noted that the Veteran has documentation in recent treatment records of multiple falls with acute ankle injuries, and he now has bilateral ankle strains, with the right worse than the left at times. The examiner opined that the current left ankle strain is more likely due to post-service injuries and aging. Additional VA treatment records through 2013 further document the Veteran's complaints of pain and other symptoms of the left ankle without otherwise presenting any pertinent etiological information or further detail concerning pertinent history. The Board finds that the contemporaneous STRs presenting competent medical findings and the Veteran's own symptom reports are highly probative evidence concerning that period. The Board finds that these records reflect that the Veteran was diagnosed with a sprained ankle in service and that X-rays at that time showed severe swelling of the soft tissues around the lateral malleolus but no evidence of any bone traumatic abnormality, and that no left ankle disability was noted on his service separation examination. There is no contemporaneous evidence of symptoms or treatment concerning any left ankle disability for more than 31 years following service (from separation in November 1978, to the first treatment record for pain of the left knee in March 2010). The June 2013 VA examiner clearly concluded that the Veteran's current left ankle disability is not caused by or a result of his military service. The Board finds that the June 2013 VA examination report is highly probative in this case. The report (which is found to be adequate) contains competent medical opinions addressing the pertinent etiological questions with clear conclusions and analytical rationales; it is informed by review of the claims file, interview of the Veteran, and direct medical inspection of the Veteran's left ankle disability. The Board has reviewed the entirety of the evidence of record but finds that there is no persuasive evidence of record which probatively contradicts the findings presented in the most probative evidence discussed above with regard to the matter of a left ankle disability. The Board acknowledges that the claims file contains a quantity of other medical records, but none of the information in these records pertinently contradicts the conclusions or cited rationales of the evidence found to be most probative in the discussion above. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Here, the Veteran did not have documented reported symptoms of the left ankle at the time of his separation from service. The lower extremities were evaluated by military medical personnel as clinically normal. This suggests that it was the opinion of the medical examiners that no ankle abnormalities were detected. It is also significant that there is no persuasive evidence of the claimed left ankle disability for many years following service. The Veteran has been afforded a VA examination in connection with his claim; the examiner provided negative nexus opinions. The June 2013 VA examiner provided persuasive rationale discussed above that addressed the Veteran's in-service injury history, his post-service injury history, and the significance of his specific ankle symptom history and clinical findings. To the extent that the Veteran's statements suggest a continuity of lay-perceivable symptoms after his alleged in-service injury, such assertions are inconsistent with the discharge examination report which shows that he denied pertinent problems and the April 1981 examination which shows that he stated that the left ankle had not given him problems since service. Such statements made many years after the fact are of diminished credibility when viewed against the overall evidence. The Veteran has clearly received treatment for the claimed left ankle disability since 2010, but this appears to have begun approximately 32 years after service; the Veteran's own reports consistently place the onset of his symptoms several years after his separation from service. The post-service medical records do not reflect any continuity of symptomatology, medical treatment, or other manner of perception of pain or pathology of the left ankle in the years proximately following service. The Court has indicated that normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claims. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Given the facts that (1) the STRs do not diagnose any chronic claimed disability, (2) the first evidence of any chronic claimed ankle disability is not shown until at least 31 years after service, and (3) the medical evidence of record fails to relate any currently existing claimed ankle disability to active service, the Board finds that the Veteran's statements are afforded low probative value as to the onset and etiology of his current chronic left ankle disability. In sum, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim. As such, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for left ankle disability is denied. See 38 U.S.C.A § 5107. Psychiatric disability Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Where the veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, then the veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997). Service department records must support, and not contradict, the claimant's testimony regarding noncombat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). On July 12, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. Specifically, the final rule amends 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and adding a new paragraph (f)(3) that states: If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire; including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 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). The Veteran's STRs reflect that in December 1977 he complained of difficulty sleeping at night for the previous 6 months; the assessments included insomnia and probable anxiety neurosis. In June 1978, he complained of feeling depressed and anxious. On July 1978 psychiatric evaluation, the diagnosis was inadequate personality, with depression; the examiner opined that although the Veteran was doing well for several years, after his marriage had deteriorated his heart was no longer in an Army career, and aspects of his inadequacy had become evident. The examiner noted that the Veteran's mental status did not reveal any major mental illness, nor was he showing any signs of psychosis. He showed ineffectual responses to emotional, social, intellectual and physical demands, and he manifested inadaptability, ineptness and very poor judgment. It was psychiatrically recommended that the Veteran receive a Chapter XIII discharge due to his personality disorder. On September 1978 service separation examination, the Veteran's psychiatric findings were normal on clinical evaluation. In a contemporaneous report of medical history, the Veteran checked the appropriate boxes to endorse a history of frequent trouble sleeping, depression or excessive worry, and nervous trouble of any sort. The Veteran's SPRs indicate that he received an Article 15 in April 1978 due to not being at his appointed place of duty. His DD 214 reflects that his military occupational specialty (MOS) was fabric repairman, with the related civilian occupation of canvas cover repairman. The Board notes that the Veteran's service records do not suggest that his service likely exposed him to circumstances consistent with an allegation of fear of hostile activity. On April 1981 VA examination, the Veteran showed no undue emotional reaction or any undue signs of tension. A May 1981 rating decision denied a claim of service connection for nervousness, noting that the Veteran was seen two or three times in service for nervousness, he was hospitalized for four days in July 1978, and the diagnosis following the hospitalization was inadequate personality with depression, as a result of which he was discharged from service. The rating decision noted that personality disorders, in and of themselves, are considered to be developmental or congenital abnormalities and not disabilities for which compensation can be paid. The subsequent post-service medical records contain diagnoses of schizophrenia, schizoaffective disorder, depression and PTSD. On July 1990 psychological consultation, the Veteran was noted to have recently been discharged from a drug and alcohol program, to which he had been admitted due to depression and suicidal ideation. He reported symptoms of impulsive buying, nightmares, sleep onset insomnia, and blank periods with childhood onset when he did not know about activities he did during that time. He was noted to be under psychiatric treatment for five years. On November 1995 psychological evaluation, the diagnoses included psychotic disorder not otherwise specified, delusional disorder persecutory type, schizophrenia paranoid type, alcohol abuse, other substance abuse, factitious disorder not otherwise specified, and malingering, as well as Axis II diagnoses of schizotypal personality disorder and paranoid personality disorder. On February 1996 mental health intake evaluation, the Veteran reported auditory hallucinations for over a year as well as worsening nightmares and poor sleep. He complained of feeling tormented by demons, one of which he believed he had first encountered as a child. He reported that he was placed in foster care after his mother killed his father, who had been raping his sisters; he reported that he was in nine different foster homes in the first two years, and he was sexually abused by foster parents from the age of 7 to 14. He reported no military stressor incidents. Following a mental status evaluation, the diagnoses included chronic PTSD and rule-out schizophrenic disorder. Social Security Administration records reflect that, in a January 1997 decision, the Veteran was found to be disabled since November 1995 due to PTSD and major depression with psychotic features; his PTSD was noted to include recurrent and intrusive recollections of his traumatic childhood experiences as a source of marked distress. On March through September 2003 treatment records, the assessments included schizoaffective disorder and PTSD, and noted the Veteran's regimen of psychotropic medications. On January 2005 and subsequent VA treatment records, the diagnoses include schizophrenia. On May 2005 VA treatment, the assessments included schizoaffective disorder, PTSD due to severe past traumas, alcohol abuse, and cocaine and cannabis abuse in remission since 1990. On August 2005 VA treatment, the Veteran reported that he was not sleeping due to nightmares about being abused as a child; the problem with sleep came and went and had been a major concern for over two years. On October 2005 VA treatment, the diagnoses included PTSD due to witnessing his mother kill his father in self defense and physical and sexual abuse in foster care homes; schizoaffective disorder by history with features of depressed mood and periodic auditory hallucinations; and polysubstance abuse in long-term full remission. On June 2006 VA psychiatric examination, the examiner noted the Veteran's ongoing psychiatric treatment, with the most recent diagnosis of schizoaffective disorder and questions about possible PTSD; the Veteran's history of early childhood traumas was discussed. The Veteran was noted to be on many psychotropic medications including aripiprazole, benztropine, mirtazapine, zolpidem, and trazodone, as well as prazosin for nightmares. The Veteran gave a complex history of a difficult life, including witnessing his mother kill his father when he was about 6 years old, after which he spent 12 years in a variety of foster homes where he reported physical, verbal, and sexual abuse. He reported being in nine different foster homes during one two year period. He reported that he joined the army after quitting school in 12th grade. Regarding his military experience, the Veteran reported that he served in Germany from late 1973 until 1975 when terrorist attacks were occurring, some directed at the American military. He reported that he was on guard duty one night when he was confronted by someone with an AK-47 assault rifle, although no shots were fired. He stated that, as a result of his handling of the incident, he was given an Article 15 punishment rather than any counseling. He stated that he began drinking heavily which continued for the rest of his military career. He reported that his work effectiveness fell off and he tried to kill himself on two occasions. He reported that he finally had a psychiatric hospitalization, he told the doctors he wanted out of the Army, and he was discharged. He reported that he qualified for Social Security Disability benefits based on a schizoaffective condition. Following a mental status examination, the diagnoses included schizoaffective disorder, most recent episode depressed, severe; and polysubstance abuse reported in long full remission. The VA examiner opined that, from the history given, it is possible the Veteran suffered PTSD prior to entering the Army although he was never diagnosed or treated and he did not describe major difficulties prior to his tour in Germany; the examiner noted the Veteran's statements that he enjoyed basic training and truck driver training and did quite well, which argued against the presence of a major psychiatric condition up to that point. However, the examiner opined that the events of his troubled childhood more likely than not predisposed the Veteran to an anxiety disorder or other serious mental illness later on. Based on the history reported, the examiner noted that the Veteran appears to have had what amounted to an emotional and behavioral collapse in Germany, with two suicide attempts, although he was not given a major psychiatric diagnosis but rather an administrative discharge on the grounds of a personality disorder. The examiner opined that this would not be an unusual occurrence in the life of someone destined to manifest eventual symptoms of schizophrenia or a schizoaffective disorder. The examiner noted that the prodrome of such a serious condition frequently could be mistaken for that of a personality disorder, although it was unclear from the Veteran's reported history just when his psychotic symptoms began; the examiner noted the Veteran's report that he worked full time for about seven years after leaving the Army, as overt psychosis probably did not emerge within the first several years after discharge, although heavy alcohol use confounds the picture for that time period. The examiner opined that, given the Veteran's probable predisposition to PTSD from childhood traumas, he could have interpreted a stressful guard duty event as being life threatening and even terrifying, therefore if such an episode were administratively verified, in view of the Veteran's reported fear and horror, such an episode could be deemed a sufficient stressor to precipitate PTSD. The examiner opined that about two thirds of the Veteran's difficulty relates to his schizoaffective disorder and the rest of PTSD type symptoms. The examiner further opined that, based on the history alone, it is not unlikely that the situation in Germany, reportedly necessitating psychiatric hospitalization, more likely than not represented the prodrome of the schizoaffective disorder which emerged later in full form several years after discharge. In a July 2006 addendum opinion following a review of the claims file, the June 2006 VA examiner noted that the medical records show varied diagnostic impressions dating back to at least 1996, usually including an affective component and some variety of an anxiety disorder, often PTSD. The examiner noted that the onset of the Veteran's hallucinations was described as about one year prior to 1996, which was long after the Veteran's 1978 discharge from service. The examiner noted the STRs including the July 1978 psychiatric admission for inadequate personality with depression, citing that the Veteran was said to have been depressed since 1976, with separation from his wife as the listed stressor. The examiner noted the July 1978 psychiatric examination report supporting administrative discharge, at which time no psychosis of major mental illness was found; marital problems were cited, with deterioration of performance and loss of interest in a military career. The examiner noted that there was no mention in any military documents of any traumatic occurrence while the Veteran was on guard duty. The examiner found that the records do not show a diagnosis of PTSD or a schizophrenic/schizoaffective disorder while the Veteran was in service, although they do show evidence of emotional disturbance, with both anxiety and depression noted, as well as marked deterioration in function. The examiner noted that there is no firm evidence of the existence of a diagnosed mental disorder prior to enlistment. The examiner opined that the in-service events may well have been the prodrome of a later-emerging psychotic disorder, but there is a long time gap between the Veteran's discharge from service and any overt major illness, with self-described very heavy alcohol use clouding the picture for several years. The examiner reiterated the opinion that the Veteran would meet the requirements for a PTSD diagnosis if his reported terrifying event on guard duty were to be verified; however, the examiner continued that the one administratively solid diagnosis is that of schizoaffective disorder, which did not become fully manifest for a number of years after service, even if his symptoms in Germany represented a prodrome of such a condition. On November 2009 VA psychiatric examination, the examiner noted the findings on the June 2006 examination, including the Veteran's contention of a stressor event that occurred in Germany when he was confronted by someone with an assault rifle, which had resulted in continuing nightmares and intrusive thoughts. The Veteran had stated that the only documentation of the occurrence might be in Article 15 disciplinary proceedings that were held against him afterwards; on review of the claims file, the examiner noted that the Veteran was cited with an Article 15 violation because of a failure to report for duty on one occasion in April 1978. The examiner concluded that there does not appear to be any documented information about the stated confrontation with someone pointing a rifle. The examiner noted upon review of the claims file that none of the STRs contain any specific detail about psychiatric symptomatology except for the diagnoses rendered. On examination, the Veteran contended that the alleged stressor event in Germany occurred in December 1973, during his first assignment there, although he had trouble recalling for certain when it occurred. Following service, the Veteran reported that he was an alcoholic for 12 years until he sought help and became sober. He first sought mental health treatment in 1998 for depression; subsequent to the initial evaluation, he was consistently assessed as manifesting symptoms consistent with schizoaffective disorder, depressive type, for which he has been on a variety of medications. Regarding his personal history, the Veteran reported a chaotic upbringing, witnessing his mother killing his father in self-defense after the father had sexually abused the Veteran and his oldest sister, and living in more than 20 foster homes throughout his childhood, where he was subjected to physical and sexual abuse. Following a mental status examination, the examiner's diagnoses included schizoaffective disorder, depressive type by history; and chronic moderate PTSD. The examiner opined that it is not possible to reconcile the apparent disparity between the stated times of occurrence of the Veteran's in-service traumatic event; however, the claims file does not contain confirmation that the Veteran in fact was potentially assaulted by an unknown attacker. The examiner noted that the Veteran described the event in a fairly clear way and stated that he has recurrent nightmares about the episode. The examiner also acknowledged that the Veteran was subjected to extreme physical, emotional, and sexual abuse during his developmental years, and he quite possibly entered into active duty service with some PTSD symptoms. As a corollary, the examiner noted that the Veteran described himself in high school as being very shy, and he gave a history of a very isolated and mistrustful lifestyle. The examiner noted that the treatment records recurrently reflect a diagnosis of schizoaffective disorder, yet opined that it would be pure speculation to link the appearance of schizoaffective disorder sometime in the mid-1990s to psychiatric symptoms experienced while on active duty in service; nevertheless, he met the criteria for such a diagnosis. Regarding the existence of PTSD, the examiner opined that the Veteran did perceive that he was threatened by an unknown person with a weapon while on duty in Germany, and the date of that occurrence appears to have been December 1973; the examiner opined that it appears to be at least as likely as not that the Veteran's current PTSD symptoms are linked to this stressor. Regarding PTSD, while the Veteran has been consistently diagnosed with such disability, the relaxed evidentiary standards of the revised 38 C.F.R. § 3.304(f)(3) do not apply in this case, given the circumstances of the Veteran's service and the nature of his allegations. He has not been assigned a diagnosis of PTSD based on fear of hostile military or terrorist activity. Indeed, despite the November 2009 VA examiner's opinion that his current PTSD symptoms are linked to the alleged stressor of being confronted with an assault rifle while serving on guard duty one night in Germany, this event has not been verified by any corroborating evidence. The Board notes that the Veteran's stressor accounts are simply not credible. "Credibility can be genuinely evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, official plausibility of the testimony, and the consistency of the witness's testimony". The Veteran's accounts of the claimed in-service stressor have been inconsistent, and are self-serving. See Pond v. West, 12 Vet. App. 341 (1999). Further, the Board finds that the circumstances of his service do not allow for a finding of fear of hostile military or terrorist activity, and the Veteran did not even assert this alleged in-service stressor until June 2006. Notably, on February 1996 mental health intake evaluation, the Veteran reported no military stressor incidents, and chronic PTSD was diagnosed based on his traumatic childhood experiences. The January 1997 Social Security Administration decision found the Veteran to be disabled since November 1995 due in part to PTSD, which was noted to include recurrent and intrusive recollections of his traumatic childhood experiences as a source of marked distress; there was no mention of any military stressor. The Veteran's own statements indicate that the only existing documentation of the alleged in-service stressor event would be the Article 15 he received, yet the only such Article 15 in his SPRs was in April 1978 due to not being at his appointed place of duty, with no mention of any assault rifle confrontation. In summary, the record does not show that the Veteran engaged in combat with the enemy, and there is no evidence of circumstances consistent with the possibility that he may have served in circumstances that may reasonably be found to create a fear of hostile military activity. There is no valid diagnosis of PTSD based on a corroborated stressor. As a threshold legal requirement for establishing service connection for PTSD is not met, service connection for such disability is not warranted. As the record shows diagnoses of psychiatric disabilities other than PTSD, the analysis proceeds to whether any other psychiatric disability diagnosed may be service connected. A chronic acquired psychiatric disability was not noted in service or clinically noted post-service prior to 1990, and service connection for a psychiatric disability on the basis that such disability became manifest in service and persisted is not warranted. As a psychosis is not shown to have been manifested in the first postservice year, the chronic disease presumptive provisions of 38 U.S.C.A. §§ 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 do not apply. The preponderance of the evidence is against a finding that any current psychiatric disability is related to service. Although certain comments by examiners are to the effect that certain inservice mental health symptoms may have been early suggestions of mental health problems to come, such comments are clearly speculative and couched in terms of possibility. The persuasive medical evidence is to the effect that the actual chronic disorders diagnosed after service were not actually manifested during service. The evidence is not in a state of equipoise on the question of nexus between any diagnosis of a psychiatric disability and the Veteran's service. Simply stated, the Board finds that the service and post-service treatment records, overall, provide evidence against this claim, indicating that the Veteran does not have a current psychiatric disability related to service. More importantly, the more competent evidence of record provides evidence against a finding that any current psychiatric disability was incurred in or caused by the Veteran's active service. Regarding the Veteran's own opinion that he has a psychiatric disability that is due to his service, he is a layperson (with no demonstrated or alleged expertise in determining a medical nexus); does not offer any supporting medical opinion or medical treatise evidence; does not cite to any supporting factual data; and does not offer any explanation of rationale for his opinion. Therefore, his opinion in this matter has no probative value. The Board recognizes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2007). That is, competent medical evidence is not necessarily required where the determinative issue in a case involves medical causation or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. Sept. 14, 2009), citing Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this case, the Veteran is not providing statements related to the diagnosis of a simple disorder or about symptomatology supporting a later diagnosis; instead he is rendering an opinion to the effect that he has a specific mental disability that is related to events in service. A mental disability is not one capable of lay diagnosis, nor is it the type of condition that can be causally related to military service without medical expertise. Davidson, 581 F.3d 1313; Buchanan, 451 F.3d 1331; Jandreau, 492 F.3d 1372. The diagnosis and etiology of a psychiatric disease are matters of medical complexity. The Veteran does not cite to supporting medical opinion or medical literature, and statements as to the diagnosis and etiology of his current psychiatric disability do not constitute probative evidence in the matter. Accordingly, the preponderance of the evidence is against the Veteran's claim of service connection for acquired psychiatric disability, to include PTSD, depression, and schizoaffective disorder, and the appeal in the matter must be denied. ORDER Service connection is not warranted for left knee disability, for left ankle disability, or for acquired psychiatric disability. The appeal is denied as to all issues.. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs