Citation Nr: 1336233 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 10-19 090 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Whether new and material evidence has been submitted in order to reopen a previously denied claim of entitlement to service connection for a sesamoid fracture to the left foot. 2. Entitlement to service connection for a psychiatric disability, claimed as posttraumatic stress disorder (PTSD) and depression. 3. Entitlement to service connection for headaches. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD B. Thomas Knope, Counsel INTRODUCTION The Veteran served on active duty from December 1986 to November 1988, and also served in the Army Reserve. This matter is on appeal from a December 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran testified before the undersigned Veterans Law Judge in June 2010. A transcript of the hearing is of record. During the course of the appeal, the issues of entitlement to service connection for depression and for PTSD have been addressed as separate and distinct claims. However, a claim of entitlement to service connection for a psychiatric disability encompasses all psychiatric disabilities that may reasonably be encompassed by evidence of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The two claims have been combined into a single issue. The claim for service connection for headaches is remanded to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. An April 2003 rating decision denied service connection for a sesamoid fracture in the left foot on the basis that it was not shown in service, nor was it incurred during any period of active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA). 2. The evidence added to the record since the April 2003 decision became final, when viewed by itself or in the context of the entire record, does not relate to an unestablished fact that is necessary to substantiate the claim of service connection for a sesamoid fracture in the left foot and does not create a reasonable possibility of an allowance of the claim. 3. A diagnosis of PTSD has not been made in connection with a stressor event that has been corroborated. 4. A psychiatric disability other than PTSD is not shown in service or for many years thereafter, and is not shown by competent evidence of record to be related to service or to any period of ACDUTRA or INACDUTRA, and no psychosis is shown within one year of separation from active duty. CONCLUSIONS OF LAW 1. The April 2003 rating decision that denied entitlement to service connection for a sesamoid fracture to the left foot is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2013). 2. The evidence received subsequent to the April 2003 rating decision is not new and material, and the requirements to reopen the claim for entitlement to service connection for a sesamoid fracture to the left foot have not been met. 38 U.S.C.A. §§ 5108, 7105 (West 2002 & Supp. 2013); 38 C.F.R. § 3.102, 3.156 (2013). 3. A psychiatric disability, to include depression and PTSD, was not incurred in or aggravated by service and is not related to service. 38 U.S.C.A. §§ 1110, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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) (West 2002); 38 C.F.R. § 3.159(b) (2013); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements apply to all five elements of a service-connection claim, to include Veteran status, existence of a disability, a connection between service and the disability, degree of disability, and effective date of the disability. Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded should be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). There are additional notice requirements for claims to reopen based on new and material evidence, such as notifying a claimant of the evidence and information that is necessary to reopen the claim and of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). Here, neither the Veteran nor the representative has alleged prejudice with respect to notice, and none is found by the Board. Shinseki v. Sanders, 556 U.S. 396 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The duty to notify was satisfied by a letter sent to the Veteran in July 2008 that fully addressed all notice elements and was sent prior to the initial RO decision. The letter informed her of what evidence was required to substantiate the claims and of her and VA's respective duties for obtaining evidence. It also provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, notice of the type of evidence necessary to establish an effective date, and the basis for the denial where the claim had been previously considered. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of her case to the Board. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Next, VA has a duty to assist a Veteran in the development of a claim. That duty includes assisting in the procurement of service medical records and other pertinent records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). After a careful review of the file, the Board finds that all necessary development has been accomplished, and appellate review may proceed. Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service medical records and VA outpatient treatment records and records submitted in conjunction with a claim to the Social Security Administration (SSA). While the RO was unable to acquire any treatment records from the Veteran's Army Reserve unit, the Board is satisfied that a diligent effort was made to acquire the records and the Veteran has had the opportunity to furnish any unavailable records. Moreover, the Veteran has not indicated that any further records exist. Also, the Veteran submitted treatment records from a private facilities and her own statements in support of her claim. A VA examination with respect to the psychiatric disorder claim was obtained in September 2008, which was accompanied by an addendum in October 2008. 38 C.F.R. § 3.159(c)(4) (2013). When VA provides a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the VA examination is adequate because it is predicated on a full understanding of the Veteran's medical history, and provides a sufficient evidentiary basis for the claim to be adjudicated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2013). The Board acknowledges that a VA medical opinion was not obtained regarding a psychiatric disorder other than PTSD. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. § 3.159(c)(4) (2013). A VA examination is not required as a matter of course in virtually every veteran's disability case involving a nexus issue. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran, in which case an examination may not be required). Here, there is no evidence of any psychiatric disability during either active duty or during any period of ACDUTRA. As a result, there is insufficient evidence upon which an adequate opinion can be based. Therefore, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). New and Material Evidence In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. Manio v. Derwinski, 1 Vet. App. 140 (1991). New evidence means evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. If VA finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the Veteran in developing the facts necessary for the claim has been satisfied. Elkins v. West, 12 Vet. App. 209 (1999). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110 (2010). Only evidence presented since the last final denial on any basis will be considered in the context of the entire record to determine whether new and material evidence has been submitted. Evans v. Brown, 9 Vet. App. 273 (1996). However, for the purpose of establishing whether new and material evidence has been received, the credibility of the new evidence is presumed, unless patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994); Justus v. Principi, 3 Vet. App. 510 (1992). The Veteran is seeking entitlement to service connection for residuals of a fracture to the sesamoid bone in the left foot. At her hearing before the Board in June 2010, she stated that this injury occurred during a weekend drill period with the Army Reserve. That claim was previously denied by the RO in April 2003 on the basis that a sesamoid fracture was not shown in service or for a substantial amount of time thereafter, and was unrelated to active duty or to any period of Reserve service, or any period of ACDUTRA or INACDUTRA. While the Veteran submitted a notice of disagreement in July 2003, the RO determined that letter not sufficiently specific, and did not constitute a valid notice of disagreement for VA purposes. 38 C.F.R. § 20.201 (2013). She did not contest that determination, nor did she submit any new and material evidence within a year of the April 2003 rating decision. Buie v. Shinseki, 24 Vet. App. 242 (2011). That represents the last final denial of the claim. The evidence of record at the time of the April 2003 rating decision included the Veteran's service medical records and personnel records from her Army Reserve service. The evidence also included private treatment records from a Dr. J.M. from 1995 to 1998, and VA treatment records from 2002 and a VA examination from June 1989. The evidence since the April 2003 rating decision includes additional private treatment records from the Providence Portland Medical Center from 2000 to 2002, and the Portland Adventist Medical Center from 1999, and the records retained by the SSA. The evidence also includes the most current VA treatment records and VA examination reports from September and October 2008. Based on the review of the evidence submitted since the last final denial of this claim, the Board determines that none of it is new and material to this issue on appeal, and reopening the claim is not warranted. Almost all of the records acquired since the April 2003 decision relate to the Veteran's psychiatric claim, and do not relate to her prior sesamoid fracture. Additionally, the evidence that does relate to the Veteran's prior sesamoid fracture does not address an unestablished fact necessary to support entitlement to service connection. For example, while VA treatment notes in April 2003 and November 2006 mention her prior injury, neither indicates that the sesamoid fracture was related to her active duty or reserve service. Even though a large number of records were obtained from the SSA, only one treatment note from May 2000 indicated symptoms in the Veteran's left foot, and that note did not indicate whether those symptoms were related to her prior sesamoid fracture. Therefore, while that evidence is new in that it had not been previously considered by the RO, it is nonetheless not material, as it does not indicate that her sesamoid fracture occurred during active duty or any other period of service. Therefore, the new evidence does not create a reasonable possibility of an allowance of the claim. While the Board has also considered the Veteran's more recent statements regarding her injury, her assertions that her sesamoid fracture was related to an injury in service are duplicative of the statements already included in the claims file and considered in the prior final decision. Reid v. Derwinski, 2 Vet. App. 312 (1992). Moreover, while the record also includes statements from friends and family members who knew the Veteran, none of those statements addressed her sesamoid fracture. Thus, the Veteran's statements don not constitute new and material evidence. Therefore, the Board concludes that new and material evidence has not been submitted to reopen the claim of entitlement to service connection for residuals of a sesamoid fracture to the left foot. Therefore, the appeal is denied. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Generally, the evidence 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 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). In some cases, inservice incurrence and a casual relationship to service may be established through a demonstration of continuity of symptomatology for certain specific chronic disorders. 38 C.F.R. § 3.303(b) (2013); Barr v. Nicholson, 21 Vet. App. 303 (2007). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). However, service-connection may be established under 38 C.F.R. § 3.303(b) only for disorders considered chronic. Psychoses are considered a chronic disease. 38 C.F.R. § 3.309(a) (2013); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Nevertheless, evidence of continuous symptoms since active duty is still a factor for consideration as to whether a causal relationship exists between an in-service injury or incident and the current disability. 38 C.F.R. § 3.303(a) (2013). Service connection will also be presumed for a psychosis if manifest to a compensable degree within one year after discharge from service. 38 C.F.R. §§ 3.307, 3.309 (2013). Active service includes any period of ACDUTRA during which the individual was disabled from a disease or an injury incurred in the line of duty, or a period of INACDUTRA during which the appellant was disabled from an injury incurred in the line of duty. 38 U.S.C.A. 101(24) (West 2002); 38 C.F.R. § 3.6(a) (2013). ACDUTRA includes full-time duty in the Armed Forces performed by the Reserves for training purposes. 38 U.S.C.A. § 101(22) (West 2002); 38 C.F.R. § 3.6(c) (2013). INACDUTRA includes duty prescribed for the Reserves. 38 U.S.C.A. § 101(23)(A) (West 2002). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. 38 U.S.C.A. § 1110 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. 38 U.S.C.A. § 1154(a) (West 2002); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran is claiming entitlement to service connection for a psychiatric disability, which has been characterized as PTSD, depression, or schizoaffective disorder. It is her primary assertion that she has PTSD following a sexual assault that occurred while she was serving on a period of ACDUTRA in 1998. PTSD At a hearing before the Board in June 2010, the Veteran explained that she had entered into a relationship with another reservist, but despite the fact that she had ended the relationship, the other reservist continued to stalk her, and ultimately raped her at gunpoint during a period of ACDUTRA in 1998. Despite that alleged incident, the alleged perpetrator continued to attempt to contact her throughout the following year. In order to establish service connection for PTSD, the evidence of record must include a medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2013). A diagnosis of a mental disorder conform to the American Psychiatric Association, Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) (1994). 38 C.F.R. § 4.125(a) (2013). As set forth in the DSM-IV, a valid diagnosis of PTSD requires that a person has been exposed to a traumatic event in which both of the following were present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others, and (2) the person's response involved intense fear, helplessness, or horror. Typically, if a Veteran did not engage in combat with the enemy, as is the case here, the Veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the Veteran's testimony as to the occurrence of the claimed stressor. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d), (f) (2013); West v. Brown, 7 Vet. App. 70 (1994). However, for claims of PTSD based on a personal assault in service, evidence from sources other than the Veteran's service records may corroborate the account of the stressor incident. Examples of that evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(4) (2013). The Board finds that service connection is not warranted for PTSD based on a personal assault, because the evidence does not show that it is at least as likely as not that a diagnosis of PTSD is appropriate. There are some instances where PTSD was diagnosed. For example, the Veteran has submitted two statements from December 2007 and July 2009 by a nurse practitioner who diagnosed the Veteran with PTSD that was due to the rape she experienced while on active duty. More recent treatment records, such as in February, May, and September 2008 considered that diagnosis of PTSD was a possibility, although PTSD was not explicitly diagnosed. However, substantially all of the other psychiatrists who have evaluated the Veteran declined to diagnose PTSD. For example, when she underwent an initial psychiatric evaluation in May 1999 with complaints of increased depression and suicidal ideation, she also presented symptoms of paranoid ideation and objectively suspect fears, such as that people were following her and that her telephone line was bugged. At no time on that occasion did she mention a prior personal assault and, notably, the evaluating psychiatrist diagnosed her with depression with psychotic features rather than PTSD. At a psychodiagnostic evaluation in May 2010, the Veteran stated that she was experiencing relationship problems, and that she had been experiencing depression-like symptoms since 1993. The psychologist who evaluated her noted that the Veteran did not appear psychotic, but "her presentation was unusual." As was the case in 1999, the Veteran was diagnosed with depression as opposed to PTSD. At a subsequent evaluation in May 2002, the Veteran continued to make very unusual statements, such as claiming to have been monitored by the FBI for the past few years, and believing that she may have killed someone. There was no mention of a personal assault, and the evaluating psychiatrist ultimately diagnosed schizoaffective disorder with psychotic symptoms. Another evaluation in June 2002 revealed similar psychotic symptoms such as poverty of thought, auditory hallucinations, and paranoid delusions, to include claiming to be accused of murder. She also did not appear to be aware of why she was there. Her diagnosis was again limited to bipolar disorder with psychotic features rather than PTSD. The Veteran was again admitted for psychiatric evaluation in October 2003. On that occasion, she indicated that she was experiencing suicidal ideation because the FBI was constantly following her because she was under suspicion of murdering a woman named "Keri." Notably, even though she stated that she was raped in 1995 (which was inconsistent with her statements at her hearing before the Board), the evaluating physician noted that the Veteran's had exhibited psychotic behavior since approximately 1997, and diagnosed her with psychosis rather than PTSD. Significantly, the Veteran underwent a VA psychiatric examination in September 2008 with a licensed clinical psychologist. After a thorough psychiatric evaluation and a review of the claims file, the examiner stated that it was "clear that the primary disabling psychiatric disorder for this veteran is schizoaffective disorder," which was significantly disabling by itself. While the examiner recognized that the Veteran had reported some symptoms of PTSD to other treating clinicians, and asserted that such symptoms were due to a sexual assault, the examiner noted that the she also has a history of distorted perceptions, and delusional thinking had been documented on a number of occasions. As a consequence, the VA examiner did not diagnose PTSD. In October 2008, the VA examiner provided an additional comment that even though the Veteran may have been demonstrating some PTSD-type symptoms, a diagnosis of PTSD was nevertheless not warranted because it did not appear that she met the formal diagnostic criteria for PTSD based on the examiner's assessment and review of the claims file. Considering that evidence, the Board finds that the opinions provided by the VA examiner outweigh the statements by the nurse practitioner because of the greater level of training of the examiner. Furthermore, the other psychiatric physicians who did not find a diagnosis of PTSD appropriate add weight to the findings of the examiner. The Board finds that the preponderance of the evidence shows that a diagnosis of PTSD is not the appropriate diagnosis in this case. In so concluding, the Board notes that opinion provided by VA psychiatric examiner is of high probative value because of the access to the Veteran's treatment records and history, the higher credentials and level of training of the examiner, and the thorough explanation in the examination report following examination of the Veteran. In determining that the Veteran does not have a current diagnosis of PTSD, the Board recognizes that a disorder need only be manifest at some point during the pendency of that claim, even if no disability is present at the time of the claim adjudication. McLain v. Nicholson, 21 Vet. App. 319 (2007). However, this is not a situation where the Veteran had a legitimate prior diagnosis that has since resolved. Rather, the Board has determined that the weight of the clinical evidence is against the conclusion that a diagnosis of PTSD has been appropriate during the pendency of the appeal. The Board finds that the preponderance of the evidence shows that different psychiatric diagnoses are appropriate.. The Board finds that service connection is not warranted unless the evidence indicates that a current disability exists. 38 U.S.C.A. § 1110 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board also notes that, even if a diagnosis of PTSD was warranted based on the evidence of record, service connection would still not be for application, as the evidence does not indicate that her claimed stressor could be corroborated. As an initial matter, the Board notes that she never reported the incident. To be clear, the failure to report such an incident is not dispositive. However, the Veteran reported the alleged perpetrator to authorities, but her accusation was only for stalking. An actual physical assault was not alleged at that time and, when the alleged perpetrator was interviewed, the subject of an assault was never raised. Moreover, a number of the psychiatrists who evaluated her appear to doubt the veracity of her recollections. For example, a psychiatrist in May 1999 noted that the Veteran's accusations were unconfirmed and "likely paranoid" and, as was well explained by the VA examiner in September 2008, her reports about the location and time of the alleged assault have been inconsistent. The accuracy of her recollections is further clouded by the fact that the she had reportedly engaged in a consensual relationship with the alleged perpetrator apparently both before and after the alleged incident. Finally, as the VA examiner noted, the Veteran's recorded history of "distorted perceptions" and delusional thinking significantly inhibited the Board's ability to rely on the accuracy of her statements. Therefore, the Board concludes that the evidence does not support the conclusion that the Veteran has a valid diagnosis of PTSD and, in any event, there is insufficient evidence to corroborate her alleged stressor. Consequently, service connection for PTSD is not warranted. The preponderance of the evidence is against the claim for service connection for PTSD and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Other Psychiatric Disabilities The Board has also considered whether service connection is warranted for any of the Veteran's other diagnosed psychiatric disabilities, but concludes that service connection is not warranted. The service medical records that are available do not show complaints of, treatment for, or diagnoses related to any psychiatric disability while in service. The post-service evidence does not show any psychiatric symptoms for many years after the Veteran left active duty service. Specifically, the first indication of a psychiatric disability was not until January 1997, where she complained of insomnia. While a specific diagnosis was not provided, the evaluating physician believed that the Veteran had "a major mood disorder." The Board emphasizes that this first indication of those symptoms was not until 9 years after she left active duty. She has not asserted that either disability was related to her active duty service. As for the Veteran's assertions that her psychiatric symptoms are attributable to a period of ACDUTRA or INACDUTRA, the clinical evidence of record does not indicate the presence of an injury during any training period that would give rise to the claimed conditions. While she has mentioned in her claim that the disorders were incurred during training, she has not made such assertions while being examined. The Board finds that a continuity of symptoms is not shown based on the clinical evidence since active duty or since any period of active duty, ACDUTRA, or INACDUTRA. Next, service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's claimed disorders to any period active duty, despite her contentions to the contrary. Significantly, none of the competent evidence of record indicates a relationship between a non-PTSD psychiatric disorder and active duty or any period of ACDUTRA or INACDUTRA, nor has any treating professional indicated such a relationship. In arriving at this conclusion, the Board has also considered the statements made by the Veteran and others relating her psychiatric disorders to her service. 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Veteran is not competent to provide testimony regarding the etiology of her psychiatric disorders. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Because psychiatric disorders are not diagnosed by unique and readily identifiable features, they do not involve a simple identification that a layperson is competent to make. Therefore, the unsubstantiated statements regarding the claimed etiology of the Veteran's psychiatric disabilities are found to lack competency. Accordingly, the Board concludes that none of the diagnosed psychiatric disabilities can be related to her active duty service or to any period of ACDUTRA or INACDUTRA. Because the preponderance of the evidence is against the claim, the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER New and material evidence having not been submitted, the application to reopen a previously denied claim of entitlement to service connection for a sesamoid fracture to the left foot is denied. Service connection for a psychiatric disability is denied. REMAND VA has a duty to assist claimants in the development of facts pertinent to claims and VA must accomplish additional development of the evidence if the record currently before it is inadequate. 38 U.S.C.A. § 5103A (West Supp. 2010). The Board finds that a VA examination is needed in this case. The service medical records shows that the Veteran had a fracture of the right orbital bone in service in March 1988 when struck. She now complains of headaches that she attributes to her service. An examination is needed so that an examiner can opine as to whether any current headaches are related to service or to the orbital bone fracture and trauma during service. Accordingly, this case is REMANDED for the following: 1. Schedule the veteran for a VA examination to determine the etiology of any current headaches. The examiner should review the claims file and should note that review in the examination report. Specifically the examiner should provide the following information: (a) Diagnose any current headache disability. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any current headache disability is related to service or to the right orbital bone fracture during service. 2. Then, readjudicate the issue on appeal. If any decision is adverse to the veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The veteran is hereby informed that failure to report for a scheduled examination or failure to cooperate with any requested development may result in the denial of the claim. 38 C.F.R. § 3.655 (2010). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for development or other action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs