Citation Nr: 1334889 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 09-08 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder. 2. Entitlement to service connection for dysthymia and generalized anxiety disorder and insomnia. ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran, who is the Appellant, served on active duty from December 1992 to December 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions, dated in April 2007 and April 2008, of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In December 2010, the Board asked the Veteran to clarify whether he wanted the Oregon Department of Veteran Affairs as his representative or he could appoint a different representative or he could represent himself. The Veteran was notified that if he did not respond, the Board would proceed with appellate review and assume that the Veteran was representing himself. As the Veteran did not reply, the Board will assume that he is representing himself. In February 2011, the Board remanded the claim for additional development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. The Veteran did not serve in combat, posttraumatic stress disorder was not diagnosed in service; there is no credible evidence of fear of hostile military or terrorist activity, or credible evidence of a noncombat in-service stressor to support a diagnosis of posttraumatic stress disorder. 2. Dysthymia, generalized anxiety disorder and primary insomnia clearly and unmistakably pre-existed service and did not increase in severity during service. CONCLUSIONS OF LAW 1. The criteria for service connection for posttraumatic stress disorder have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304, (2013). 2. The criteria for service connection for dysthymia, generalized anxiety disorder, and primary insomnia have not been met. 38 U.S.C.A. §§ 1110, 1153, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2013). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 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. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (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 VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre-adjudication VCAA notice by letters in June 2006 and September 2007. As for the content and the timing of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (pre-adjudication VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained service treatment records and VA records. The Veteran was afforded a VA examination in March 2008, but the Board determine that the medical opinion based on the examination was inadequate. In August 2012 and in July 2013, in accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, the Board obtained a medical expert opinion from the Veterans Health Administration (VHA). As the VHA medical opinion was based on a review of the Veteran's history and described the disabilities in sufficient detail so that the Board's review is a fully informed one, the VHA opinion is adequate to decide the claims. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). The Veteran was provided a copy of the VHA opinion and afforded the opportunity to submit additional evidence and argument. There is no record of response from the Veteran. As there is no indication of the existence of additional evidence to substantiate the claims, the Board concludes that no further assistance to the Veteran in developing the facts is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Principles of Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). The showing of a chronic disease in service requires a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 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). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). The Veteran does not assert that he was in combat, and the combat provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. 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 Veteran. 38 U.S.C.A. § 5107(b). Posttraumatic Stress Disorder Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) , that is, a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f). Unless posttraumatic stress disorder is diagnosed in service and the in-service stressor is related to service, or the in-service stressor is related to combat or to fear of hostile military or terrorist activity, or to a prisoner -of-war experience, or to a personal assault, the Veteran's lay testimony alone may not establish the occurrence of an alleged noncombat in-service stressor. Otherwise the record must contain credible supporting evidence that the alleged noncombat in-service stressor actually occurred. 38 C.F.R. § 3.304(f). Facts The service treatment record shows that on entrance examination in July 1992 the Veteran gave a history of insomnia and having received counseling because of an abusive father. In July 1994, he was treated for complaints of difficulty sleeping over several years and he was referred for a psychology consultation. The psychologist noted complaints of nervousness, edginess, easily irritated, and symptoms of depression, although the Veteran denied feeling depressed. The impressions were primary insomnia, adjustment disorder with mixed emotions, and generalized anxiety disorder. The Veteran was referred for further evaluation, but records of any further evaluation or treatment are not available. After service, in May 2007, the assessment by VA was posttraumatic stress disorder, posttraumatic stress disorder related to family of origin, and generalized anxiety disorder. In July 2007, Veteran described a lack of sleep and debilitating depression and anxiety since he was discharged from the service in 1996. The Veteran stated that he went from an extremely abusive home situation to the Marines to a cult for six years, which affected him. The assessments included PTSD, depression, generalized anxiety disorder, and insomnia. In March 2008 on VA examination, the Veteran related PTSD to his childhood, which was exacerbated by the Marines and other events. He stated that after service he was in a cult for six years. The Veteran described physical and sexual abuse as a child and that he was not mentally ready for what he faced in Marines. He stated that he was overseas in the Gulf War and that he did no see combat. The Veteran complained of nightmares about his experience in the Marines and in a cult. The Veteran stated that the nightmares were not of any specific traumatic event, rather the nightmares were about getting others out of the Marines or out of a cult. The diagnoses were posttraumatic stress disorder, dysthymia, generalized anxiety disorder, and primary insomnia. The VA examiner stated that although not diagnosed before service, generalized anxiety disorder and primary insomnia preceded service and were aggravated by the Veteran's experiences in service and with a cult. The VA examiner stated that one-third of the Veteran's overall symptoms were aggravated by service. In July 2010, a VA screening test for PTSD was negative. In December 2010, "likely PTSD" with frequent intrusive memories of past abuse to some extent connected to childhood, military, and a cult was noted. In March 2011, the Veteran identified the stressors to support his claim of service connection for posttraumatic stress disorder, namely, that in Kuwait in 1995, he saw blown up Iraqi military vehicles with human remains inside. He also stated that he was a target of harassment because of his pre-existing anxiety, depression, and insomnia. He stated that his experiences in the U.S. Marines exacerbated his symptoms. In August 2012 and in July 2013, the Board obtained an opinion from a VHA expert, a psychiatrist, on the following questions: Is it obvious that the Veteran had a pre-existing psychiatric disorder? If it is obvious that the Veteran had a pre-existing psychiatric disorder, was the pre-existing psychiatric disorder permanently worsened in service beyond the natural course of the condition? If the Veteran did not have an obvious pre-existing psychiatric disorder is it more likely than not (probability greater than 50 percent), at least as likely as not (probability approximately 50 percent), or less likely than not (probability less than 50 percent) that any current psychiatric disorder represents a progression of the diagnostic impressions in service or the development of a new and separate psychiatric disorder? If, however, after a review of the record, an opinion on an association between any current psychiatric disorder and service is not possible without resort to speculation, please clarify whether such an association cannot be determined because there are several potential causes, when the Veteran's in-service experience is not more likely than any other to cause the Veteran's current psychiatric disorder(s) and that an opinion is beyond what may be reasonably concluded based on the evidence of record and current medical knowledge. After a review of the Veteran's file, the VHA expert stated that on the basis of a history of abuse in childhood and subsequent examinations the Veteran had developed generalized anxiety disorder and primary insomnia prior to service. The VHA expert stated that the Veteran's nightmares were not consistent with a diagnosis of PTSD, because the nightmares did not relate to a specific event in service. The VHA expert that there were many confounding factors contributing to the Veteran's presentation, but the core issue points to pre-existing severe childhood abuse, anxiety, and insomnia. The VHA expert expressed the opinion that there was undebatable evidence from the service records that there was no increase in the pre-existing generalized anxiety disorder, primary insomnia, and dysthymia during service beyond natural progress. Analysis Posttraumatic Stress Disorder On the basis of the service treatment records, posttraumatic stress disorder was not affirmatively shown during service and service connection under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(a) is not established. Posttraumatic stress disorder is not a chronic disease under 38 C.F.R. § 3.309, and the principles of service connection pertaining to chronicity and continuity of symptomatology under 38 C.F.R. § 3.303(b) and presumptive service connection as a chronic disease under 38 C.F.R. § 1112 do not apply. See Walker v. Shinseki, 708 F.3d (Fed. Cir. 2013) (The continuity of symptomatology avenue to service connection under regulation creating presumption of service connection for chronic diseases manifesting during service and then again at any later date is available only for chronic diseases enumerated in the only regulation listing named chronic diseases. 38 C.F.R. §§ 3.303(b), 3.309(a)). The Veteran is competent to describe psychiatric symptoms. 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); see Layno v. Brown, 6 Vet. App. 465, 469-71 (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 testimony is competent only so long as it is within the knowledge and personal observations of the witness). Also the Veteran as a lay person is competent to identify a simple medical condition, or describe a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran as a lay person is also competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Under 38 C.F.R. § 4.125, the diagnosis of posttraumatic stress disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which requires medical evidence diagnosing the condition. And posttraumatic stress disorder is not a type of condition under case law that has been found to be capable of lay observation. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (it is generally the province of medical professionals to diagnose or label a mental condition). As posttraumatic stress disorder is not capable of lay observation under 38 C.F.R. § 4.125 or by case law, posttraumatic stress disorder is not a simple medical condition. And no factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to diagnose posttraumatic stress disorder. Where, as here, there is a question of the diagnosis of posttraumatic stress disorder, which is not capable of lay observation under 38 C.F.R. § 4.125 or by case law, to the extent the Veteran's lay statements are offered as proof of the presence of posttraumatic stress disorder in service, the Veteran's lay statements are not competent evidence, and the Veteran's lay statements are not admissible as evidence, that is, the Veteran's lay statements are not to be considered as competent evidence that posttraumatic stress disorder as was present in service and the lay evidence cannot be considered as evidence favorable to the claim. Although service connection for posttraumatic stress disorder is not established by affirmatively showing onset in service under 38 C.F.R. § 3.303(a) on the basis of lay evidence, service connection may still be established based on an initial diagnosis after service, when all of the evidence, including that pertinent to service, shows that the disability was incurred in service. 38 C.F.R. § 3.303(d). As for Veteran's assertion that posttraumatic stress disorder is related to service, which is an expression of a causal relationship, the statement is an inference based on facts, that is an opinion, rather than a statement of fact. As previously explained, posttraumatic stress disorder is not capable of lay observation, that is, a simple medical condition under 38 C.F.R. § 4.125 or by case law and any inference based on what is not personally observable cannot be competent lay evidence. And no factual foundation has been established to show that the Veteran is otherwise qualified through specialized education, training, or experience to offer an opinion on the causal relationship or nexus between posttraumatic stress disorder and service. For these reasons, the Veteran's lay opinion is not competent evidence. Since the Veteran's lay opinion is not competent evidence, the lay opinion is excluded, that is, not admissible as evidence and cannot be considered as competent lay evidence favorable to claim and as the evidence is not admissible, the Board need not reach the credibility under 38 C.F.R. § 3.303(d). As for Veteran describing a contemporaneous medical diagnosis or symptoms that later support a diagnosis by a medical professional, there is evidence for and against the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or opinion. 38 C.F.R. § 3.159. With regard to a medical opinion, the probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, whether the opinion is the product of reliable principles, and whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). A mere conclusionary opinion is insufficient to allow the Board to make an informed decision as to the weight to assign to the opinion against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). The evidence in favor of the claim consists of VA records. In May 2007, the assessment by VA was posttraumatic stress disorder and posttraumatic stress disorder related to family of origin. In July 2007, the Veteran stated that he went from an extremely abusive home situation to the Marines to a cult for six years, which affected him. The assessment was PTSD. In March 2008 on VA examination, the Veteran related PTSD to his childhood, which was exacerbated by the Marines and other events. He stated that he was overseas in the Gulf War and that he did no see combat. The Veteran complained of nightmares about his experience in the Marines and in a cult. The Veteran stated that the nightmares were not of any specific traumatic event, rather the nightmares were about getting others out of the Marines or out of a cult. The diagnosis was posttraumatic stress disorder. As an in-service stressor was not identified to support the diagnosis of posttraumatic stress disorder, the diagnosis has no probative value on a material issue of fact. As for the stressors identified by the Veteran, namely, Iraqi vehicles with human remains and being the target of harassment, the stressors are noncombat stressors, and the Veteran's statements alone are not sufficient evidence that the claimed stressors actually occurred in the absence of a diagnosis of posttraumatic stress disorder in service, or evidence of fear of hostile military or terrorist activity, or evidence of a personal assault. The medical evidence against the claim consists of the opinion of the VHA expert. As the Veteran's statements alone are not sufficient evidence that the claimed noncombat stressors actually occurred, the VHA expert addressed the Veteran's nightmares, but found that the nightmares were not consistent with a diagnosis of PTSD, because the nightmares did not relate to a specific event or stressor in service. In the absence of competent medical evidence of a diagnosis of PTSD based on credible supporting of a noncombat stressor, the preponderance of the evidence is against the claim. As there is no competent evidence to support the claim of service connection, considering all the evidence, including the lay and medical evidence, the preponderance of the evidence is against the claim and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Dysthymia and Generalized Anxiety Disorder and Insomnia Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled into service, except as to disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. 1111; 38 C.F.R. § 3.304(b); VAOPGCPREC 3-03, and Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The presumption of soundness attaches only where there has been an entrance examination that did not note the disability that the Veteran later complains of. The term "noted" means only such conditions that are recorded at the time of the examination. A "history" alone of a preservice existence of a condition recorded at the time of examination does not constitute a notation of such a condition. 38 C.F.R. § 3.304(b). The burden then falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that a disease manifested in service was both preexisting and not aggravated by service. 38 U.S.C.A. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed.Cir.2004). A preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153. Clear and unmistakable evidence means that the evidence that is undebatable. Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (citing Vanerson v. West, 12 Vet. App. 254, 258-59 (1999)). Once the presumption of soundness applies, the burden of proof is on VA on both the preexistence and the aggravation prongs and the burden of proof does not shift. Even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness. See Routen v. West, 142 F.3d 1434, 1440 (Fed.Cir.1998) ("When the predicate evidence is established that triggers the presumption, the further evidentiary gap is filled by the presumption."). In rebutting the presumption of soundness, VA may show a lack of aggravation by establishing with clear and unmistakable evidence that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. See Wagner, 370 F.3d at 1096. On service entrance examination in July 1992, the Veteran gave a history of insomnia and having received counseling because of an abusive father. In July 1994, he complained of difficulty sleeping since the age of 13. On a psychology consultation, the psychologist noted the Veteran's complaints of nervousness, edginess, easily irritated, and symptoms of depression, although the Veteran denied feeling depressed. The impressions were primary insomnia, adjustment disorder with mixed emotions, and generalized anxiety disorder. At that time, the Veteran was referred for further evaluation, but records of any further evaluation or treatment are not available. On VA examination in March 2008, the VA examiner stated that the diagnoses of primary insomnia and generalized anxiety disorder were continuations of the diagnoses made in service, but that the Veteran had clearly stated that his symptoms preceded his entry into military service although no diagnosis had been made. Based on the Veteran's report of pre-existing symptoms, the VA examiner stated that: It is more likely than not that the symptoms were aggravated by Veteran's service experience. It is also likely that the symptoms were aggravated by his cult experience after service and that the symptoms that were aggravated in service were only a portion of the Veteran's symptoms. The Board obtained an opinion from a VHA psychiatrist. After a review of the Veteran's file, the VHA expert stated that the Veteran had developed generalized anxiety disorder and primary insomnia prior to service. The VHA expert expressed the opinion that there was undebatable evidence from the service records that there was no increase in the pre-existing generalized anxiety disorder, primary insomnia, and dysthymia during service beyond natural progress. As a psychiatric disorder was not noted on the Veteran's entrance examination, the presumption of soundness attaches. 38 U.S .C. A. § 1111. The burden then falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. The record shows that on service entrance examination in July 1992 there was a history of insomnia and that the Veteran had received counseling because of an abusive father. During service, the impressions were primary insomnia, adjustment disorder with mixed emotions, and generalized anxiety disorder. On VA examination in March 2008 the Veteran stated that his symptoms of anxiety and insomnia preceded his entry into military service, and the VHA expert found that primary insomnia and generalized anxiety disorder developed prior to service. In the absence of an assertion by the Veteran that he had not made the statements attributed to him in service, the Veteran's in-service statements is clear and unmistakable evidence to rebut the presumption of soundness as to a pre-existing condition. Horn v. Shinseki, 25 Vet. App. 231, 237-38 (2012). In addition to requiring VA to prove by clear and unmistakable evidence that the condition pre-existed service, under the same evidentiary standard, VA must show that the pre-existing condition was not permanently aggravated by service. While the VA examiner stated that one-third of the Veteran's symptoms could be considered to have been aggravated by service, the VA examiner did not describe permanent aggravation of a pre-existing disability beyond natural progress. In contrast, the VHA expert specifically found undebatable evidence from the service records that there was no permanent increase in the pre-existing conditions of generalized anxiety disorder, primary insomnia, and dysthymia during service beyond natural progress. To the extent the Appellant has expressed the opinion that the pre-service psychiatric condition was aggravated by service, the Veteran's lay opinion is limited to inferences that are rationally based on his perception and that does not require specialized education, training, or experience. It is not argued or shown that the Veteran is qualified through specialized education, training, or experience to offer medical diagnosis or medical opinion. The Veteran as a lay person is therefore not competent to offer an opinion on whether the pre-existing psychiatric condition was permanently made worse, that is, aggravated by service. Accordingly, based on the evidence of record, and in the absence of any competent evidence to the contrary, the Board finds by clear and unmistakable evidence that the pre-existing psychiatric condition, variously diagnosed as dysthymia, generalized anxiety disorder, or primary insomnia, was not aggravated during service, and service connection for the pre-existing psychiatric condition is not warranted. ORDER Service connection for posttraumatic stress disorder is denied. Service connection for dysthymia and generalized anxiety disorder and insomnia is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs