Citation Nr: 1340246 Decision Date: 12/05/13 Archive Date: 12/20/13 DOCKET NO. 05-10 558A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a skin condition, other than chloracne, to include lipomas, as due to in-service herbicide exposure. 2. Entitlement to service connection for a skin condition, other than chloracne and lipomas, to include as due to in-service herbicide exposure. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1958 to December 1972 and has additional service in the Mississippi National Guard from November 1977 to November 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In August 2004, in pertinent part, the RO denied the Veteran's claims of entitlement to service connection for a skin disorder other than chloracne and declined to reopen a previously denied claim for service connection for PTSD on the basis that new and material evidence had not been received. In June 2007, the Veteran and his spouse testified before the undersigned Veterans Law Judge, seated at the RO in Jackson, Mississippi. A transcript of the hearing has been associated with the claims file. The Travel Board hearing was sufficient to fulfill his right to a hearing under 38 C.F.R. § 20.700(a) (2013). In December 2007, the Board determined that new and material evidence had been received and reopened the Veteran's claim of entitlement to service connection for PTSD. The Board remanded the reopened issue, together with the issue of entitlement to service connection for a skin disorder other than chloracne, for additional development. The Board again remanded the issues for additional development in April 2011. In November 2012, the Board requested an advisory medical opinion from the Veterans Health Administration (VHA) in regards to the issue of entitlement to service connection for a psychiatric disorder, to include PTSD. A VHA advisory opinion report was received in January 2013. Thereafter, the Board wrote to the Veteran and notified him of the receipt of the VHA opinion and return of the case to the Board for further appellate proceedings. In a February 2013 response, the Veteran stated he was submitting additional evidence and he was not waiving consideration by the RO and wanted the claim remanded to the RO for consideration of this evidence in the first instance. The Board remanded the two service connection claims for adjudication by the RO as requested by the Veteran in June 2013. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. As reflected on the first page of this decision, the Board has separated the issue of entitlement to service connection for a skin condition, other than chloracne, into two issues for skin condition. FINDINGS OF FACT 1. The Veteran's July 1958 enlistment examination shows he had history of cyst removals from his right and left ears and he had a purulent sebaceous cyst on his left ear. 2. The preponderance of the competent medical evidence of record is against a finding that the Veteran's pre-existing scars from surgically removed cysts on his right and left ears and sebaceous cyst on his left ear were aggravated by his period of service, to include his in-service exposure to herbicides. 3. The Veteran's lipomas on his back were first incurred during his active service. 4. The Veteran's statements concerning his combat experiences in the Republic of Vietnam are found to be credible and consistent with his service. 5. The weight of the competent medical evidence of record is against a finding that that the Veteran has a current diagnosis of PTSD in accordance with § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 6. The Veteran's personality disorder is a congenital or development defect not subject to compensation within the meaning of applicable legislation, and there is no evidence that shows a superimposed disease or injury during service created any additional psychiatric disability. 7. The Veteran's current diagnosed acquired psychiatric disorder was not shown during service, or for years thereafter, and the weight of the medical evidence is against a link between any current or previous diagnosed psychiatric disorder and service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a skin condition, other than chloracne and lipomas, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2013). 2. The criteria for entitlement to service connection for lipomas on the back have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2013). 3. The criteria for entitlement to service connection for acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 4.125 (2013); VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice required by the VCAA can be divided into three elements. Specifically, VA must inform the claimant of any information and evidence not of record: (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In view of the Board's favorable decision to grant service connection for lipomas on the back, any further discussion as to any lapses in duties to assist and notify, or regarding whether the Veteran was prejudiced by any such lapses, would serve no useful purpose. With regard to the other claims on appeal, in June 2004, before the initial adjudication of the claim, the Veteran was notified of the evidence not of record that was necessary to substantiate the claim. He was told that he needed to provide the names of persons, agencies, or companies who had additional records to help decide his claim. He was informed that VA would attempt to review his claim and determine what additional information was needed to process his claim, schedule a VA examination if appropriate, and obtain service, VA, or private treatment reports as indicated. With respect to the Dingess requirements, the Veteran was not provided with notice of the type of evidence necessary to establish a disability rating or effective date for the disability on appeal until after his claims were initially adjudicated in August 2004. As this decision confirms the RO's denial of benefits for PTSD and pre-existing residual scar from cyst removal on the right ear and left ear cyst, and the Veteran is therefore not prejudiced in regards to lack of Dingess notice as pertaining to his claims. Proceeding with these matters in its procedural posture would not therefore prejudice the Veteran. There is no allegation from the Veteran that he has any evidence in his possession that is needed for a full and fair adjudication of this claim. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. The purpose behind the notice requirement has been satisfied and the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. In addition to its duty to notify, or inform, the Veteran with regard to his claim, VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and records of pertinent medical treatment since service, and providing the Veteran a medical examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the Veteran's service treatment records and all identified, authorized, and relevant post-service treatment records relevant to the issue on appeal have been requested or obtained, including those records maintained by the Social Security Administration. Accordingly, all available records and medical evidence have been obtained in order to make an adequate determination as to this claim. The Board acknowledges that attempts to obtain a complete copy of the treatment records from San Antonio VA medical facilities have not been successful. The record does contain a March 1992 VA dermatology consultation report from the VA medical facilities in San Antonio as well as a February 1992 Vet Center referral from the clinic in San Antonio. An April 2011 response from the San Antonia VA medical facility noted that all the chart records were transferred to the Southeast Louisiana VA medical facilities in 1992. In April 2012, a negative response was received from the Southeast Louisiana VA medical facilities regarding any treatment records for the Veteran. The Veteran was subsequently notified of the unsuccessful efforts to obtain these records. The Board also acknowledges the Veteran's contention that a complete set of his service treatment records, and in particular, his records from 1958 to 1966, have not been associated with the claims folder. However, the Board notes that a review of the service treatment records does contain his 1958 entrance examination report. The Veteran has not specifically asserted that there is any particular missing record from 1958 to 1966 that pertains to his claims on appeal. Moreover, the record does contain his treatments record through the remainder of his active service until he separated in 1972. The Board finds that a remand for a search of possibly missing service treatment records would serve no purpose at this time. In addition, VA has afforded the Veteran with VA afforded VA skin examination in July 2009 and April 2011 and a VA psychiatric examination in July 2009 with an addendum statement dated in May 2011. These examination reports show that the examiners reviewed the medical evidence of record, including the Veteran's service treatment records and the findings from his medical treatment records. In addition, the Board has obtained a VA expert medical opinion in January 2013 that addresses whether the Veteran has a current diagnosis of PTSD in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. This report demonstrates that the VA medical expert reviewed the evidence of record and rendered an appropriate opinion based on the question presented by the Board. This opinion was rendered after a thorough review of the claims file and is supported by the evidence of record. The Board acknowledges the Veteran's contentions that the July 2009 VA skin and psychiatric examinations are inadequate as well as his contentions regarding the adequacy of the January 2013 medical expert's opinion. The Veteran asserted that the VA examiner who conducted the July 2009 VA psychiatric examination was unprofessional and the VA examiner who conducted the July 2009 VA skin examination was not qualified as dermatologist specialist. See September 2010 statement in support of the case, as well as various other statements from the Veteran. The Veteran was afforded another VA skin examination in April 2011 and he has questioned the adequacy of that VA examination report. In regard to July 2009 VA psychiatric examination report, the Board notes that other than the Veteran's assertion, there is no indication in the record to question the professionalism and integrity of the July 2009 VA examiner. The Board notes that a review of VA examination report shows that it consists of eight page, single spaced report that contains a detailed account of the Veteran's reported medical history and reported in-service stressors as well as findings from clinical examination. Also, any possible deficiency in the July 2009 VA psychiatric examination report was resolved by the January 2013VA medical expert opinion report. The Board notes that the Veteran questioned whether the January 2013 VA medical expert had fully access to his claims folder; however, in the report, the VA medical expert specifically stated that he reviewed the all the available evidence I the claims folder. He stated that despite the Veteran's reports that the record lacked several years of his military service treatment records and records from San Antonio VA medical facility, he was able to render his medical conclusion with reasonable certainty. The Board finds that the Veteran's assertion in no way imposes an additional burden on VA to provide the Veteran with a new VA examination or medical opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the medical opinions are adequate for adjudication purposes, and the adequacy of this medical opinion is discussed in further details below. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO/AMC has substantially complied with the Board's remand instructions in December 2007 and April 2011. Stegall v. West, 11 Vet. App. 268, 271 (1998). In sum, the Board finds the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandate of the VCAA. Additionally, the Board finds there has been substantial compliance with its remand directives. The Board notes that the U.S. Court of Appeals for Veterans Claims (Court) has recently held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.) The record indicates that pursuant to the Board's December 2007 and April 2011 remand directives, the Appeals Management Center (AMC) requested the Veteran to identify any outstanding relevant treatment records, afforded the Veteran VA skin examinations in July 2009 and April 2011 and VA psychiatric examination in July 2009 with an addendum statement dated in May 2011, and most recently issued a Supplemental Statement of the Case in July 2013. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Therefore, the Board will proceed to review and decide the claim based on the evidence that is of record consistent with 38 C.F.R. § 3.655. 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Skin Conditions Other than Chloracne The Veteran seeks entitlement to service connection for a skin condition, other than chloracne. He asserts that his current diagnosed skin conditions are related to his period of service, to include his in-service exposure to Agent Orange. As the Veteran served in Vietnam during the Vietnam Era and his exposure to herbicide agents, to include Agent Orange, is presumed. See 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). With in-services exposure to herbicide agents, service connection is presumed for conditions identified as related to such exposure and itemized at 38 C.F.R. § 3.309(e). However, the Veteran's current diagnosed skin disorders of lipomas and residual scars are not among the conditions itemized at 38 C.F.R. § 3.309(e) and recognized as a disease for which presumptive service connection is available on the basis of herbicide exposure. Service connection on a presumptive basis is not warranted. See 38 C.F.R. § §3.307, 3.309(e). Notwithstanding the inapplicability of the regulations pertaining to presumptive service connection, the Board is obligated to fully consider the Veteran's claim on a direct basis. See Combee, 34 F.3d at 1039. In regard to direct service connection theory of entitlement, the remaining question on appeal is whether the Veteran has any current skin disorders, other than chloracne that is related to his period of service, to include his in-service exposure to herbicides. The evidence before the Board includes record of the Veteran's July 1958 physical examination conducted for the purpose of entry into service. At that time, the Veteran presented with a purulent cyst of the left pinna and a one-inch scar of the right ear from cyst removal, well-healed, without sequelae. The examiner noted that cysts had been removed and treatment was on-going. Service treatment records dated in July 1970 indicate that the Veteran presented with scars of previous acneform, eruption free. At the time of his April 1972 physical examination conducted for the purpose of separation from service, the Veteran presented with two lipomas on his back. Subsequent to service, the Veteran has been treated for a rash, an epidermal cyst, seborrheic keratosis, cysts, acne vulgaris, papillomatous lid lesions, and epidermal inclusion cysts. A March 1992 Agent Orange Examination shows findings of multiple cysts on the face and back. At the time of his August 2005 Agent Orange examination, the examiner noted that on physical examination the Veteran had popular lesions and seborrheic keratoses on his chest and back. The Veteran underwent VA skin examination in July 2009. At that time, the examiner asserted that there was no evidence of skin changes consistent with chloracne, to include cysts, large open comedones, or pustules. The examiner opined that the Veteran's lipomas were not related to active service, including exposure to Agent Orange, and reasoned that such were developmental. However, the examiner also noted that the lipomas could have been related to a traumatic event. In April 2011, the Veteran was afforded another VA skin examination. The examination report shows that the examiner reviewed the medical evidence of record, including the Veteran's service treatment records and the findings from the previous VA examinations. Physical examination of the Veteran's skin revealed objective findings of residual scar on the right ear from cyst removal, which was superficial and nonpainful in nature. There were also objective findings of five lipomas on the Veteran's back. There was no objective evidence of lesion or scar on the Veteran's left ear. The VA examiner found diagnoses of lipomas, residual scar on the right ear from cyst removal. The VA examiner opined that the lipomas on the Veteran's back, first noted in 1972 on his separation examination, were "less likely as not developmental disease incurred or aggravated by service and less likely as not subjected to superimposed injury or disease during service." With regard to the right ear residual scar, the examiner opined that "it is less likely as not it represented disease or injury that underwent [an] increase in severity during service and at least as likely as not with increase in severity due to natural progression of the disease." Residual Scars on Left and Right Ears Initially, the Board notes that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or 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. Clear and unmistakable evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). VA's Office of General Counsel has issued a precedent opinion holding that in order to rebut the presumption of soundness in 38 U.S.C.A. § 1111, VA must demonstrate by clear and unmistakable evidence both that the disease or injury in question existed prior to service and that it was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. In this case, the Veteran's 1958 enlistment medical history report shows that the Veteran reported that he had undergone cyst excision from his right ear prior to his enlistment into service and his enlistment physical examination report noted a purulent cyst of the left pinna and a one-inch scar of the right ear from cyst removal, well-healed, without sequelae. Consequently, the Board finds that the Veteran's enlistment demonstrates that he was not in sound condition at induction with respect to residuals of cysts on his right and left ear, and thus he is not entitled to the presumption of soundness as to that condition. 38 U.S.C.A. § 1111; see also Paulson v. Brown, 7 Vet. App. 466, 468 (1995). Therefore, the issue in this case is whether the Veteran's residual of cysts on his right and left ear were aggravated by his period of service as contemplated by 38 U.S.C.A. § 1153. In this regard, the Board must first consider whether the evidence of record shows that the Veteran's condition increased in severity during his period service. The Veteran's 1972 separation examination report does not reflect any objective findings of residual of cysts either ear. In addition, during clinical examination in April 2011, there were no findings of residual of cyst on the left ear and the residual scar on the right ear was evaluated as superficial and nonpainful. There is no evidence that suggests that the Veteran's pre-existing residual of cyst on his right ear and cyst of the left ear increased in severity during the Veteran's period of service. Moreover, the April 2011 VA examiner found that the Veteran's period of service did not aggravate, or cause the permanent increase in his pre-existing residual scar of cyst excision from the right ear. The Board notes that there are no medical opinions of record to the contrary. Other than the Veteran's assertions, there is no evidence of record that indicates that his pre-existing residual scar from excision of cysts on the right ear and cyst on the left ear were aggravated by his service. The Board finds that the Veteran's assertions as to etiology of his medical condition are afforded little probative weight in the absence of evidence that the Veteran has medical training that can provide the expertise to render opinions about medical matters. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Where the determinative issue involves a medical opinion, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical etiology do not constitute competent medical evidence, when the question involving etiology goes beyond mere observations. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting that a veteran is competent to provide a diagnosis of an observable condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In this regard, the consideration of whether his pre-existing residual scar and cyst were permanently worsened beyond the natural progression of the disease is a matter of internal medicine that requires medical expertise. As such, the Veteran's statement that his pre-existing residual scar and cyst on his ears were permanently worsened as a result of his period of service is of no probative value. Here, the evidence of record does not show that the Veteran's pre-existing residual scar on the right ear and cyst on his left ear were not permanently aggravated as a result of his period of service. Specifically, this medical evidence is found in the April 2011 VA examiner's medical statement, which demonstrates that there was no evidence of a permanent increase in the Veteran's pre-existing residual scar from excision of cysts on the right ear and left ear cyst by his period of service. In short, the preponderance of the competent evidence of record is against a finding that the Veteran's pre-existing residual scar from excision of cysts on the right ear and left ear cyst were aggravated by his period of service. See 38 C.F.R. § 3.306(b). Lipomas In this case, the Veteran asserts that service connection for lipomas on his back is warranted. The record shows that the Veteran was first diagnosed with two lipomas on his back in service, and that he has a current diagnosis for lipomas on his back. Service connection is warranted for a disability first incurred in service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303(a). Here, the record shows that the Veteran was first diagnosed with two lipomas on his back at the time of his separation from service in 1972, and that he has a current diagnosis of multiple lipomas on his back. The post-service treatment records reflect a continuity of symptoms and indicate that the Veteran's disability has increased in severity as the number of lipomas has increased and further treatment for his disorder has been recommended. The Board acknowledges that the April 2011 VA examiner opined that the Veteran's lipomas were likely developmental in nature and were less likely than not the result of a superimposed injury or disease. However, the Board cannot ignore the previous 2009 medical finding that the Veteran's lipomas could have been the result of a traumatic event. As such, the Board finds that the weight of the relevant evidence of record is at least in equipoise that the Veteran has current lipomas on his back likely began during service. See Hickson, supra. In sum, the evidence of record shows that the Veteran's lipomas were incurred in service, and that he has a current disability due to multiple lipomas on his back. Therefore, service connection is warranted for lipomas on the back. See 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303(a). Acquired Psychiatric Disorder PTSD Service connection for PTSD requires: (1) medical evidence establishing a diagnosis of the condition pursuant to 38 C.F.R. § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); (2) credible supporting evidence that the claimed in-service stressors actually occurred; and (3) a link, established by medical evidence, between the current symptomatology and the claimed in-service stressors. 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of a recognizable in-service stressor event will vary depending upon whether a veteran engaged in "combat with the enemy". See Gaines v. West, 11 Vet. App. 353, 359 (1998). Participation in combat is determined on a case-by-case basis, and it requires that a veteran participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. See VAOPGCPREC 12-99 (October 18, 1999); Morgan v. Principi, 17 Vet. App. 149 (2003). If VA determines that a veteran engaged in combat with the enemy and his alleged stressor is combat-related, then his lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required, as long as such testimony is found to be credible and "consistent with circumstances, conditions or hardships of service." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f)(1); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Here, the Veteran's service records show he had active service in Vietnam from December 15, 1966 to December 13, 1967. He served as a military policeman with the United States Air Force (USAF) with the 366th Air Police Squadron. His awards and decorations include the Combat Infantry Badge (CIB). The Veteran asserts that while he was stationed at Da Nang Air Force Base (AFB) on February 27, 1967 the base was attacked by rocket fire and 11 servicemen were killed and 124 servicemen were wounded. The Veteran also asserts that on March 15, 1967 the base was attacked by enemy fire and 7 aircrafts were damaged with no casualties. In July 2009, the Joint Services Records Research Center (JSRRC) noted research of the historical report submitted by the 366th Tactical Fighter Wing (366th TFW), the higher headquarters of the 366th Security Police Squadron, concerning the February 27, 1967 attack at Da Nang AFB. The USAF casualty data and the book titled Air Base Defense in the Republic of Vietnam 1961-73 were also researched. It was reported that on February 27, 1967, two airmen were killed and 96 members injured as a result of a hostile attack on Da Nang AFB. One member received serious fragment wounds which necessitated amputation of both arms and a leg. Da Nang sustained 56 rockets during a standoff attack. It was reported that this was the first time rockets were employed in Vietnam by the Viet Cong. Based on the JSRRC report, the Board finds that the Veteran's claimed stressor has been corroborated. Further, his statements concerning his combat experiences are found to be credible and consistent with his service. Therefore, the Veteran's statements concerning in-service stressors will be accepted as conclusive. The remaining questions before the Board regarding the claim for service connection for PTSD are (1) whether there is medical evidence establishing a diagnosis of PTSD as defined in DSM-IV, and (2) whether there is medical evidence of nexus between the diagnosis and the claimed in-service stressors. The Veteran reports that he first sought treatment for his mental health problems in the early 1990's at the VA medical facilities in San Antonio. A February 1992 referral letter from Vet Center shows that the Veteran was referred for an evaluation for PTSD due to his traumatic experiences in Vietnam. A September 2005 VA Agent Orange examination report reflects an assessment of PTSD. A January 2008 VA mental health consultation record reflects that the Veteran reported progressive depressive symptoms, obsessive behavior worsening and sleep disruption, anger and dementia. The Veteran reported significant symptoms of PTSD since Vietnam. The examiner noted that the Veteran was seen by the provider in February 2005 for the same symptoms but he denied needing any treatment at that time. It was noted that he had been taking anti-depressant medication since November 2006. Upon mental status examination, the examiner diagnosed PTSD and depression. Since then, the Veteran has undergone regular VA outpatient individual and group therapy with a nurse practitioner or psychologist. VA outpatient treatment records dated January 2008 to February 2011 reflect diagnoses of PTSD and depression. A July 2008 VA treatment record reflects a diagnosis of dementia related to multiple etiologies, to include his radiation therapy and his psychiatric disorders. In July 2009, the Veteran underwent a VA psychiatric examination. In the examination report, the VA examiner recorded the Veteran's reported in-service stressors in Vietnam, to include enemy rocket attacks. The examiner also recorded the Veteran's subjective complaints, to include: constantly thinking about Vietnam and other times in the military when he feels like he was mistreated; dreaming about Vietnam, which causes him to wake up; and feeling angry all the time and wanting to fight people constantly. The examiner noted that the Veteran denied being involved in a physical fight in years and he complained that other people will not fight him when he tries to get them to fight. He reported that he does not like to be in crowds and he likes to be alone. He goes to church services and he occasionally goes out to eat. He reported constant and chronic suicidal ideations without plan or intent. The Veteran denied any previous psychiatric hospitalizations. He complained that life at times is not worth living but he would not harm himself because of his wife. The July 2009 VA examiner noted that the Veteran completed the Trauma Symptoms Inventor, but his profile was invalid. The VA examiner found that the Veteran endorsed atypical symptoms which would not be consistent with the presentation of chronic PTSD and the Veteran was highly inconsistent in his response set. The July 2009 VA examiner concluded that the Veteran did not have objective findings of PTSD. In support of this conclusion, the July 2009 VA examiner essentially noted the Veteran did not report significant symptoms of avoidance during the evaluation. The Veteran's most significant complaint was anger, but it was noted that he was getting into fights before the military. The Veteran complained of constantly thinking about Vietnam and having nightmares, and he does not have required symptoms of avoidance. Thus, the VA examiner opined that he does not meet the criteria for PTSD. Instead, the July 2009 VA examiner recorded an Axis I diagnosis of depressive disorder not otherwise specified and Axis II diagnosis of personality disorder not otherwise specified with anti-social traits. The VA examiner commented that the Veteran appeared to be a low-average level of function and he complained of having problems understanding the testing. The VA examiner stated the evidence suggested that he had early personality issues and his current symptoms, in particular anger, and appeared to be more consistent with a personality disorder with anti-social features. In January 2013, the Board obtained a VA medical expert opinion report. In that report, the VA medical expert noted a review of all the available evidence of record. The VA medical expert stated that despite the Veteran's reports that the record lacked several years of his military service treatment records and records from San Antonio VA medical facility, he was able to render his medical conclusion with reasonable certainty. The VA medical expert concluded that based on a review of the claims folder, including the Veteran's reported statements and the findings from the 2009 VA psychiatric examination report, the evidence of record did not support a diagnosis of PTSD based on the DSM-IV criteria. The VA medical expert noted that according to the DSM-IV, a diagnosis of PTSD requires a trauma stressor and symptoms of re-experiencing the trauma, arousal symptoms, and avoidance that lead to impairment in functioning. Regarding avoidance, DSM-IV requires persistent avoidance of stimuli associated with trauma and numbing of general responsiveness as indicated by three or more of the following: efforts to avoid thoughts, feelings or conversations associated with trauma; efforts to avoid activities, places, or people that aroused recollections of trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feeling detachment or estrangement from others; restricted range of affect; and a sense of foreshortened further. The VA medical expert found that the evidence of record suggested that the Veteran "relished, rather than avoided, discussing his experiences in Vietnam." In particular, it was noted that the Veteran had previously reported to medical professionals that he spends a lot of time with his buddies rehashing their combat experiences" and he "drinks coffee with other veterans." The medical expert also noted that in a June 2007 statement, the Veteran's wife stated that the Veteran "talks a great deal about his experiences in VietNam." The examiner also noted that lay evidence of record also suggested that the Veteran was not socially avoidant until after his surgery that resulted in facial disfigurement and speech impediment. The VA medical expert also felt that the Veteran's other potential symptoms of avoidance were attributable to his other medical conditions, such as his depression and personality disorder. The VA medical expert concluded that based on a review of the record, a diagnosis of PTSD was not established. The Veteran did not meet the full criteria for PTSD, and in particular, the criterion for avoidance. The VA medical expert noted that the medical treatment notes that reflected an impression of PTSD do not address the full diagnostic criteria for PTSD. The VA medical expert felt that a review of the claims folder, and in particular, the statement from the Veteran, strongly suggested that the Veteran had a personality disorder, which was consistent with the June 2009 VA examiner opinion that the Veteran had a personality disorder, not otherwise specified with antisocial features. The evidence also supported a diagnosis of depression disorder. The crux of the matter in this case is whether the medical evidence of record establishes a diagnosis of PTSD. The record contains conflicting evidence on whether the Veteran has a current diagnosis of PTSD as defined in DSM-IV. The Veteran's treatment records from VAMC show that the Veteran has been diagnosed with and treated for PTSD; whereas, the July 2009 VA examination report and January 2013 VA medical expert opinion report ruled out a diagnosis for PTSD as defined in DSM-IV. After reviewing all the evidence, the Board finds that the VA examination and medical opinion reports are more probative, because they consisted of a complete review of the Veteran's medical records, including those earlier VA treatment records. The Board notes that the Veteran questioned the professionalism of the July 2009 VA examiner at the time of examination. Any deficiencies noted in the July 2009 VA examination report were resolved by the January 2013 VA medical expert opinion report. Based on that review, the VA medical expert opinion confirmed the impression that the Veteran did not meet the criteria for a diagnosis of PTSD. Even though the VAMC treatment records contain diagnoses that include PTSD, the Board finds that the medical impression in the 2013 VA medical expert opinion report is more probative because it considered the findings from the July 2009 VA psychiatric evaluation report as well as reviewed of the VA treatment record. Moreover, the VA medical expert supported his diagnostic impression with a rationale in light of the factual findings of the medical evidence. The VA medical expert provided findings and a rationale that showed that the Veteran's symptoms were not consistent with a diagnosis of PTSD as defined in DSM-IV. Rather, the VA examiner explained that the Veteran's symptomatology was more consistent with a diagnosis of personality disorder. Both the July 2009 VA examiner and the January 2013 VA medical expert are the only medical professional to assess the Veteran's symptoms in light of the criteria for a PTSD diagnosis as defined by DSM-IV. Those VA medical reports do not find a diagnosis of PTSD. Without a current medical diagnosis of PTSD as defined by VA regulations, VA cannot award service connection for that condition. See 38 C.F.R. §§ 3.303, 3.304(f), 4.125(a). Further, while various VA treatment records note a diagnosis of PTSD, these records do not contain a rational statement in support of that medical conclusion. In those records, the VA medical providers only record the Veteran's reported subjective history, symptoms and treatment, without clearly expressing any opinion as to whether the Veteran met the diagnostic criteria for PTSD in accordance with DSM-IV as required by VA regulations. The findings and opinions of the January 2013 VA medical expert are well supported by rationale and carry more probative weight than any medical notation with no rationale or support of the diagnosis of PTSD contained in the Veteran's VA mental treatment records. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account is of no probative value. Reonal v. Brown, 5 Vet. App. 458, 460 (1993). A medical opinion that contains only data and conclusion is not entitled to any weight. Although, the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statements. Guerrieri v. Brown, 4 Vet. App. 467 (1993). In sum, the preponderance of the competent medical evidence is against the claim of service connection for a PTSD. Even though, the Veteran's claimed inservice stressor event has been verified, the weight of the probative medical evidence of record is against a diagnosis of PTSD as defined by VA regulations. Consequently, the benefit-of-the-doubt rule does not apply and the Veteran's claim must be denied. 38 U.S.C.A. § 5107(b). Psychiatric Disorder, Other than PTSD The record shows that the Veteran has been diagnosed with psychiatric disorders other than PTSD, to include a personality disorder, depression, and dementia. The Board will now address whether service connection is warranted for any of those diagnosed psychiatric disorders. The Veteran's service treatment records dated in October 1972 indicate that his presentation was extremely anxious and he reported family problems. There is no legible diagnosis recorded at the time of this instance of treatment. Service treatment records dated in October 1972 indicate that the Veteran's psychiatric prescription medication was increased. Report of consultation at the Psychiatry Clinic, dated in November 1972, indicates that the Veteran presented without gross psychopathology. As noted above, the VA medical records also show diagnoses of personality disorder, depression and dementia. In a May 2011 addendum medical statement to the July 2009 VA examination report, the VA examiner concluded that it was less likely than not that the Veteran's current depressive disorder is related to his military service. The examiner noted that the Veteran's service treatment records show that he was prescribed medication for complaints of distress related to his marital problems; however, the November 1972 psychiatric consultation report showed "no gross psychopathology." The VA examiner found that the November 1972 finding suggested that the Veteran was having a situational problem and he did not have a significant psychiatric illness at that time or during any point of his period of service. Initially, the Board notes that congenital or developmental defects, refractive errors of the eye, personality disorders, and mental deficiency, are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c); see also, Terry v. Principi, 340 F.3d 1378, 1384 (Fed. Cir. 2003) (upholding VA's regulation that a congenital disorder is not a disease or injury as contemplated by 38 U.S.C.A. §§ 1110, 1131). VA regulations specifically prohibit service connection for congenital defects unless such defect was subjected to a superimposed disease or injury during service which created additional disability. See VAOPGCPREC 82-90. If a defect is subject to superimposed disease or injury, service connection may be warranted for the resultant disability. See 38 C.F.R. § 3.303(c); VAOPGCPREC 67-90, VAOPGCPREC 82-90. Both the July 2009 VA examiner and the January 2013 VA medical expert found that the Veteran's symptomatology was consistent with a diagnosis of personality disorder. As noted above, VA regulations specifically prohibit service connection for congenital or developmental defects unless such defect was subjected to a superimposed disease or injury during service which created additional disability. See VAOPGCPREC 82-90. Here, the Board finds no evidence of an increase in severity of the personality disorder during service or evidence of additional disability due to a superimposed disease or injury during service. Here, a review of the record does not show that the personality disorder increased in severity during his service. The Board acknowledges the Veteran was seen in service for mental health problems in October 1972 when he was prescribed medication, but the November 1972 psychiatric consultation report shows that "no gross pathology" was observed on clinical interview. In addition, the record does not show that he was never hospitalized for any psychiatric disease in service or sought subsequent mental health treatment for more than a decade after his separation from service. Significantly, the Veteran's April 1972 discharge examination notes that the Veteran received a normal psychiatric evaluation and there is no indication that the Veteran sought any subsequent in-service psychiatric care following the November 1972 consultation. The finding of normal psychiatric evaluations on separation and at the 1972 psychiatric consultation weigh against the finding that the Veteran suffered additional disability due to a superimposed injury or incurrent mental health problem during service. The lack of any continuous treatment for mental health problems over 17 years following service, also weighs against a this contention. Moreover, and more importantly, the VA examiner in the May 2011 addendum concluded the Veteran's mental health complaints in October 1972 were situational in nature and did reflect a significant psychiatric illness in November 1972 or during any point of his period of service. A temporary or intermittent flare-up of a pre-existing injury or disease is not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. Davis v. Principi, 276 F. 3d 1341, 1346- 47 (Fed. Cir. 2002); Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Here, there is no evidence that shows that the Veteran's pre-existing personality disorder increased in severity during service. As there was no indication of problems following the October 1972 treatment for distress and no finding of significant psychiatric illness at that time or during any point of his period of service, the Board concludes that the October 1972 symptomatology was only a temporary flare up of the Veteran's pre-existing personality disorder and not evidence of an increase in the pre-existing during service. Accordingly, with no showing on an increase in severity during service, inservice aggravation is not presumed. 38 C.F.R. § 3.306(a). In short, the evidence of record is against a finding that a personality disorder increased in severity during service. To the extent that the Veteran's lay statements can be interpreted as evidence that there was an increase in severity in the personality disorder resulting from a superimposed disease or injury in service, the Board finds he is not competent to diagnose a psychiatric disorder or to assess that he incurred an additional disability as the result of his service. In this regard, the Board observes that laypersons are competent to report what comes through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). However, he is not competent to diagnose a psychiatric disorder, to include aggravation of a personality disorder. Notably, the requisite knowledge to diagnose a psychiatric disorder, to include aggravation of a personality disorder, goes well beyond the capability of lay observation. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As diagnosing a psychiatric disorder is complex in nature, the Board finds that the Veteran is not competent to diagnose an acquired psychiatric disorder, to include aggravation of a personality disorder. There is no other evidence of record that suggests that there was a superimposed disease or injury during the Veteran's period of service which resulted in additional disability. In short, the personality disorder cannot be service connected unless it was subjected to a superimposed disease or injury during service which created additional disability. There is, however, no evidence showing that the personality disorder increased in severity from his experiences during his military service. See VAOPGCPREC 82-90; Terry, 340 F.3d at 1384. The Board has also considered whether service connection for a psychiatric disorder, other than personality disorder, is warranted. Here, based on a review of the evidence, the Board finds that service connection is not in order. While the record shows that the Veteran sought treatment in October 1972 for mental health problems and he was referred for a psychiatric consultation during his period of service and that he has reported experiencing mental health problems since service, the July 2009 VA examiner in her addendum medical statement ruled out a current psychiatric disorder related to service. In the May 2011 addendum medical statement, the July 2009 VA examiner confirmed that based on the reported history, clinical interview, the findings from a the examination and a review of the claims folder, that the Veteran's diagnosed depression was not related to his period of service. In support of this medical conclusion, the VA examiner noted that the Veteran's October 1972 complaints were situational and there was no evidence of a significant psychiatric illness shown in service or until a decade or more later. Also, the January 2013 VA medical expert opinion report indicates that the Veteran's current depression disorder is related to his nonservice connected residuals of malignant cancer. Pertinently, there is medical opinion of record to the contrary regarding the Veteran's depression disorder. In addition, the Veteran's VA treatment records indicate that the Veteran's dementia is the result of multiple etiologies, to include his radiation treatment, his intermittent hypotension as well as his other psychiatric disorders. See July 2008 VA treatment record. There is no indication that the Veteran's dementia is etiologically related to his period of service. The record also does not show a continuity of symptomatology (or treatment) for any psychiatric disorder, following separation from the Veteran's service in 1972 until 1989. This medical evidence comes well beyond the first year after the Veteran's discharge from his period of service. See 38 C.F.R. § 3.307, 3.309. This lengthy period without treatment for related conditions is evidence against a finding of continuity of psychiatric problems since service, and it weighs heavily against a claim for service connection on a direct basis. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). While the Veteran is competent to report his continuity of mental health symptoms since his period of service, his assertions of continuity of symptoms since service are outweighed by competent, probative evidence, to include the VA examiner's negative medical opinion on the question of whether there exists a medical nexus between such current depression disorder and service. See, e.g., Layno v. Brown, 6 Vet. App. 465, 469 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). As indicated, the Veteran has asserted continuity of mental health symptoms since service. However, the Board also points out that, in rendering the probative opinion on the question of medical nexus, the VA examiner clearly considered all pertinent evidence of record-to include the Veteran's assertions of continuity of mental health symptoms since service-and still rendered a medical opinion that is adverse to the claim. As such, the Board finds that the Veteran's assertions as to continuity of symptoms are outweighed by the VA examiner's negative medical nexus opinion. For these reasons, the Board is denying the claim for service connection for a psychiatric disorder, to include PTSD. The preponderance of the evidence is against this claim, and under these circumstances, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a skin disorder, other than chloracne and lipomas, is denied. Entitlement to service connection for lipomas on the back is granted. Entitlement to service connection for an acquired psychiatric disorder is denied. ______________________________________________ C. TRUEBA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs