Citation Nr: 1419476 Decision Date: 05/01/14 Archive Date: 05/16/14 DOCKET NO. 07-25 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, depression, and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for substance abuse. 3. Entitlement to service connection for a back disability. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for gastrointestinal problems. 6. Entitlement to service connection for a chemical imbalance. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran had active military service from March 1968 to January 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in August 2005 and October 2007 by the above Department of Veterans Affairs (VA) Regional Office (RO), which in relevant part, denied service connection for PTSD, anxiety, depression, a heart condition, hypertension, gastrointestinal problems, substance abuse, a chemical imbalance, and a back disability. In March 2009, the Board denied service connection for an acquired psychiatric disability, claimed as anxiety and depression, and remanded the claims of entitlement to service connection for PTSD, hypertension, gastrointestinal problems, substance abuse, a chemical imbalance, a heart condition, and a back disability, for further development. The appellant subsequently appealed that decision to the United States Court of Appeals for Veterans Claims, which, in December 2009 vacated the Board's March 2009 decision regarding service connection for an acquired psychiatric disability. In April 2010, the Board remanded the case for development. The case is now, once more, before the Board for appellate review. During the pendency of this appeal, in September 2011, the RO granted service connection for coronary artery disease, previously claimed as a heart condition. The Veteran disagreed with the rating assigned, and in September 2013 the RO issued a Statement of the Case. The record contains no indication that the Veteran thereafter perfected an appeal with respect to this issue, and he has not contended otherwise. Thus, this matter is not before the Board. An April 2007 VA Form 21-22a reflects that the Veteran was represented by a private attorney. In a February 2013 correspondence, however, the attorney withdrew her representation of the Veteran. Subsequently, and prior to certification of this matter to the Board in July 2013, the Veteran filed a new VA Form 21-22 in which he appointed Disabled American Veterans to act as his representative. The Board recognizes this change in representation. FINDINGS OF FACT 1. The record does not contain competent medical evidence establishing a diagnosis of PTSD based on an in-service traumatic event or stressor; an acquired psychiatric disorder was not documented during service, nor was a psychosis shown within one year of separation from service; and the weight of the competent medical evidence is against finding a nexus between the post-service diagnosis of any psychiatric disorder and service or any service-connected disability. 2. The Veteran's substance abuse and substance-induced mood disorder result from his voluntary use of drugs and alcohol and are not secondary to a service-connected disability. 3. The Veteran's back disability is not shown to have had its onset during service; arthritis of the spine was not manifest to a compensable degree within one year of separation from service; and a back disability, first documented after service, is not shown to be related to any injury, disease, or event of service origin. 4. The Veteran's hypertension was not caused or aggravated by service; it was not manifest to a compensable degree within one year of separation from service; and it is unrelated to a disease, injury, or event during service, or any service-connected disorder, to include diabetes mellitus. 5. The Veteran's gastrointestinal disability did not manifest in service and is in no way related to service or any event of service. 6. The Veteran does not have a disability diagnosed from a chemical imbalance. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for an acquired psychiatric disorder, to include PTSD, have not been met. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2013). 2. The criteria for establishing entitlement to service connection for substance abuse have not been met. 38 U.S.C.A. §§ 105, 5107 (West 2002); 38 C.F.R. §§ 3.301, 3.303 (2013). 3. The criteria for establishing entitlement to service connection for a back disability have not been met. 38 U.S.C.A. §§ 1110, 1111, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 4. The criteria for establishing entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 5. The criteria for establishing entitlement to service connection for a gastrointestinal disability have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 6. The criteria for establishing entitlement to service connection for a chemical imbalance disability have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent in August 2005, August 2006, August 2007, September 2007, July 2009, and March 2012. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letters also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disabilities under consideration, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice was timely because the claims were readjudicated in the April 2013 supplemental statements of the case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. The Veteran's service personnel records, service treatment records, available private and VA treatment records, and Social Security Administration records, have been obtained. In addition, the Veteran was provided with adequate VA examinations in connection with the claim for entitlement to service connection for an acquired psychiatric disorder. With regards to the claims for service connection for a back disorder, hypertension, and gastrointestinal problems, the RO scheduled VA examinations in April 2013, to address his medical questions, however, the Veteran failed to appear for the scheduled VA examinations and has not indicated any reason for his failure to report to the VA examinations. The RO mailed notifications of scheduled VA examinations and a subsequent supplemental statement of the case to the address of record and there is no indication that the mail was returned as undeliverable. If a Veteran relocates or changes mailing address, it is the Veteran's responsibility to notify VA. There is no burden on the part of the VA to locate the Veteran. Hyson v. Brown, 5 Vet. App. 262 (1993). The duty to assist a claimant is not a one-way street, and in this case the Veteran has failed to cooperate to the full extent in the development of his claims. Olsen v. Principi, 3 Vet. App. 480 (1992); Wood v. Derwinski, 1 Vet. App. 406 (1991). The Board concludes that in light of the Veteran's disinclination to fully cooperate, all reasonable efforts were made by VA to obtain evidence necessary to substantiate his claims and that any further attempts to assist him in developing these claims would result in needless delay, and is thus unwarranted. With regards to the claim for service connection for chemical imbalance, a VA examination is not required in the absence of competent evidence of a current diagnosed disability, and in the absence of evidence showing any event, disease, or injury during the Veteran's service, or any credible evidence relating any current disability to the Veteran's service or a service connected disability. Specific to the Veteran's claim for service connection for substance abuse, as further discussed below, a VA examination is not warranted because service connection cannot be granted on a direct basis for disabilities such as substance abuse, that are a result of willful misconduct. For these reasons, development for a VA medical examination is not warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (holding that a VA examination is only warranted when the evidence suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits); see also 38 C.F.R. § 3.159(c)(4)(i) (2013). The Board also notes that actions requested in the prior remand have been undertaken. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board is not aware, and the Veteran has not suggested the existence of, any additional pertinent evidence not yet received. Therefore, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be established 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. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic disorder manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b) (2013). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a Veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and a chronic disease, such as hypertension, psychoses, or arthritis, becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such diseases during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). 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 (West 2002). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder pre-existed service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that, effective October 10, 2006, 38 C.F.R. § 3.310 was amended to conform with Allen; however, under the facts of this case, the regulatory change does not impact the outcome of the appeal. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Acquired Psychiatric Disorder and Substance Abuse The Veteran asserts that he developed a psychiatric disability in service. Specifically, he contends that he developed PTSD due to his experiences in Vietnam, which included coming under mortar attack, and a cut to his penis incurred while having intercourse with a prostitute. He has also claimed a psychiatric disorder as secondary to a service-connected disability. Claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (under the criteria of DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2013). VA considers diagnoses of mental disorders in accordance with the American Psychiatric Association: The DSM-IV criteria for a diagnosis of PTSD include: (A) exposure to a traumatic event; (B) the traumatic event is persistently experienced in one or more ways; (C) persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness is indicated by at least three of seven symptoms; (D) persistent symptoms of increased arousal are reflected by at least two of five symptoms; (E) the duration of the disturbance must be more than one month; and (F) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). According to the DSM-IV criteria, the traumatic event, or stressor, must involve experiencing, witnessing, or being confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. In addition, the response must involve intense feelings of fear, hopelessness, or horror. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of service, lay testimony alone may establish the occurrence of the claimed stressor. 38 C.F.R. § 3.304(f) (2013). When the evidence does not establish that a Veteran is a combat Veteran, his assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, his reported service stressors must be established by official service record or other credible supporting evidence. 38 C.F.R. § 3.304(f) (2013); Pentecost v. Principi, 16 Vet. App. 124 (2002). If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. Fear of hostile military or terrorist activity means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3) (2013). The service personnel records show that the Veteran was awarded the National Defense Service Medal, Vietnam Campaign Medal, Parachute Badge, Vietnam Service Medal, and the Army Commendation Medal. He served as an electronic technician and was stationed in Vietnam from April 1969 to May 1970. Upon a review of the claims file, the Board notes that in January 2010, the Joint Services Records Research Center Coordinator determined the Veteran's unit of assignment while stationed at Camh Rah Bay did receive incoming mortar attacks; therefore, that stressor is conceded. The service treatment records contain no complaint, history or findings consistent with a psychiatric disorder, and while on ETS (expiration of term of service) examination in December 1970, he reported a history of nervous trouble, he was psychiatrically evaluated as normal. An acquired psychiatric disorder was not affirmatively shown to be present during service. After service, VA treatment records in 2003, document treatment for severe depression and grief issues. Reportedly, the Veteran had witnessed the death of his common law wife in a motor vehicle accident. The Veteran was later treated for symptoms of anxiety in 2004. In January 2005, the Veteran was given a provisional diagnosis of PTSD. Upon further evaluation, in May 2007, the Veteran was diagnosed with major depressive disorder. In April 2011, the Veteran was diagnosed with substance-induced mood disorder, major depressive disorder, recurrent alcohol dependence, cannabis dependence and nicotine dependence. Identified stressors included financial and legal problems, as well as disability issues. On VA examination in August 2011, the Veteran reported coming under mortar attack while stationed in Vietnam. He stated that at the time he feared for his life. The Veteran indicated that he was behind the lines most of the time and saw very little combat. He also reported going to Vietnam as another service stressor because he did not want to go. The examiner determined that the Veteran's overall level of traumatic stress was minimal. The examiner also noted post-military trauma that included witnessing the death of his common law wife in a motor vehicle accident in 2003, and the Veteran killing a man with subsequent imprisonment. The examiner indicated that these post-military events more likely than not accounted for some of the Veteran's PTSD-like symptoms. Following an examination of the Veteran, the examiner concluded that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. Rather, the examiner diagnosed substance-induced mood disorder, alcohol dependence in remission, and cannabis dependence in remission. The examiner identified situational stressors including financial problems and health problems. The examiner explained that the Veteran had carried a diagnosis of substance-induced mood disorder for years and his history was more consistent with that diagnosis than any diagnosis related to his military service. Substance abuse was most likely caused by or the result of polysubstance abuse and ongoing alcohol abuse, which was aggravated by negative sequali such as his eight year imprisonment. The Veteran underwent a VA PTSD examination in April 2012. The Veteran's reported in-service stressor was a cut to his penis while having intercourse with a prostitute in service. The Veteran did not describe a reaction of fear, horror or hopelessness associated with his reported in-service stressor, rather a reaction of anger. He also reported some exposure to mortar attacks while stationed in Vietnam. The examiner noted that results of the Veteran's Minnesota Multiphasic Personality Inventory-2 were consistent with somatoform disorder. Following an examination of the Veteran, the examiner concluded that the Veteran did not meet the DSM-IV criteria for diagnosis of PTSD. The examiner noted that the Veteran's stressor was not related to fear of hostile military or terrorist activity and found no exposure to a traumatic event. The Veteran's post-service imprisonment for murder was found to be his primary post-military stressor. The examiner diagnosed alcohol dependence, antisocial personality traits, and substance induced mood disorder with features of depression unrelated to military service. The Veteran's diagnoses were attributed to legal problems, unemployment, and health problems. At the outset, the Board points out that the evidence does not support a finding that the Veteran meets the criteria for a DSM-IV diagnosis of PTSD. Following an examination of the Veteran in April 2012, the examiner concluded that the Veteran did not meet the DSM-IV criteria for diagnosis of PTSD. The examiner noted that the Veteran's stressor was not related to fear of hostile military or terrorist activity and found no exposure to a traumatic event. The Veteran's post-service imprisonment for murder was found to be his primary post-military stressor. The VA examiner in August 2011 also found that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD. To the extent that the post-service treatment records noted a provisional diagnosis of PTSD in January 2005, upon further evaluation in May 2007 the Veteran was diagnosed with major depressive disorder. Moreover, the clinicians who have treated and examined the Veteran concur that the Veteran does not meet the DSM IV criteria for a diagnosis of PTSD. VA examinations in 2011 and 2012, which were based on a review of the Veteran's service and medical history, as well as his current findings, are of great probative value in this regard. As a lay person, the Veteran is not qualified or competent, through education, training, or experience to offer a medical diagnosis of a psychiatric disorder. Although the Veteran is competent to describe symptoms of anxiety and sadness, the diagnosis of a psychiatric disorder and the medical causation are not subject to lay observation. Additionally, by regulation, the diagnosis of PTSD requires medical evidence diagnosing the condition in accordance 38 C.F.R. § 4.125. 38 C.F.R. § 3.304(f) (2013). For that reason, a psychiatric disorder is not a simple medical condition that a lay person is competent to identify, and the statements of the Veteran that he has a psychiatric disorder related to service are not competent evidence. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). With regard to service connection for a psychiatric disorder, other than PTSD, it is acknowledged that in 1970 nervousness was noted. It is also acknowledged that no psychiatric disability was diagnosed during service. Additionally, post-service medical records document psychiatric treatment and diagnoses, to include major depressive disorder and anxiety. Said disabilities were diagnosed after the Veteran's separation from service. The determinative question in this case involves causation. On the question of medical causation, the medical evidence does not support the claim. 38 C.F.R. § 3.303(d) (2013). None of the Veteran's medical providers have related a psychiatric disorder to his reported in-service stressors or to any other aspect of his military service. The Veteran's symptoms of mental health disorders have been associated with situational stressors, to include the Veteran's financial problems, legal problems, his own medical problems and witnessing the death of his common law wife in 2003. A diagnosis of a psychiatric disorder was first recorded in 2003, approximately 32 years after discharge from service, and there is no indication that psychoses, had its onset during or within one year of separation from service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). To the extent that the Veteran asserts recurrence of symptomatology, the Board finds that the evidence of ongoing psychiatric symptoms fails not because of the lack of documentation; rather, the assertion of recurrence of symptoms is less probative than the other objective evidence of record. Recurrence of symptomatology is not established. 38 C.F.R. § 3.303(b) (2013); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran. Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Pond v. West, 12 Vet. App. 341 (1999) (although the Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). In considering the statements of the Veteran as to recurrence of symptomatology, in light of the evidence discussed, the Board finds that the Veteran's statements are inconsistent and contradictory to other evidence of record. At the time of separation, the Veteran was found to be psychiatrically normal, and the record demonstrates that his psychiatric problems began after the 2003 accident. The recurrence of psychiatric symptomatology has not been established, either through the competent evidence or through the Veteran's statements. To the extent that the Veteran claims that he has a psychiatric disability related to service, where the determinative issue involves a question of a medical diagnosis, not capable of lay observation, competent medical evidence is required to substantiate the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or medical opinion. 38 C.F.R. § 3.159 (2013) To the extent that the Veteran's psychiatric disorder has been attributed to disability and health issues, there is no evidence that associates any psychiatric disorder with his service-connected coronary artery disease or type II diabetes mellitus. As such there is no legal basis for entitlement to service connection for a psychiatric disorder as secondary to a service-connected disability under 38 C.F.R. § 3.310(a). Regarding the Veteran's antisocial personality traits, the Board points out that personality disorders are not diseases or injuries within the meaning of applicable legislation providing VA compensation benefits. 38 C.F.R. §§ 3.303(c), 4.9, 4.127 (2013); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996); Beno v. Principi, 3 Vet. App. 439 (1992) (holding that personality disorders are developmental in nature, and, therefore, not entitled to service connection); see also 61 Fed. Reg. 52,695 -98 (Oct. 8, 1996) (regulatory history providing that personality disorders are not diseases or injuries for VA compensation purposes). Although service connection may be granted for disability due to a superimposed disease or injury, none are shown in this case. Rather, the record reflects that the Veteran's psychiatric evaluation was normal at enlistment and normal at discharge. The Veteran has also been diagnosed with substance dependence, as well as a substance induced mood disorder. The isolated and infrequent use of drugs by itself will not be considered willful misconduct. However, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. 38 C.F.R. § 3.301(c)(3) (2013). An injury or disease incurred during active service shall not be deemed to have been incurred in the line of duty if such injury or disease was the result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. 38 C.F.R. § 3.301(d). Direct service connection may be granted only when a disability was incurred in the line of duty, and not the result of a Veteran's own willful misconduct, or for claims filed after October 31, 1990, the result of his abuse of alcohol or drugs. 38 C.F.R. § 3.301(a). There is no indication that the substance abuse is secondary to, or as a symptom of a service-connected disorder. See Allen v. Principi, 237 F.3d 1368, 1377 (Fed. Cir. 2001). The Veteran's diagnosed substance abuse, to include alcohol dependence, nicotine dependence and cannabis dependence, as well as substance induced mood disorders, cannot be service-connected. The Board has considered the research articles submitted by the Veteran in support of his claims. However, the Court has held that a medical statement and/or treatise evidence that was too generic and inconclusive as to the specific facts in a case was insufficient to establish causal link. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998); Wallin v. West, 11 Vet. App. 509, 514 (1998); Mattern v. West, 12 Vet. App. 222, 228 (1999). As the materials submitted do not specifically address the specific facts of the Veteran's claim, they are insufficient to establish an etiological nexus. In summary, in the absence of competent medical evidence of a diagnosis of PTSD that meets the DSM-IV requirements and given the weight of the competent medical evidence against a finding that any other psychiatric disorder is causally related to service, the Board finds that the preponderance of the evidence is against the claim that a psychiatric disorder was incurred in service. The evidence is also against the claim for service connection for substance abuse. As such the claims must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Back Disability The Veteran contends that he developed a low back disability during service. While in service, the Veteran received the Parachute Badge. Initially, in a Regular Army (RA) report of physical examination the Veteran reported a history of recurrent back pain, but on examination no spine pathology was noted. A history provided by the Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In this case, the presumption of soundness applies because the Veteran's spine was found to be normal on examination prior to service induction. Moreover, the presumption of soundness has not been rebutted by clear and unmistakable evidence. In this regard, there is insufficient evidence establishing that a chronic back disorder clearly and unmistakably existed prior to service. The only evidence suggesting that there may have been a pre-existing disorder is the Veteran's own reported history in February 1968 and his report of having back pain for years in January 1969. Accordingly, the presumption of soundness is not rebutted. Therefore, the disposition of this matter rests upon whether the Veteran's back disability was incurred during active service. Wagner, supra. The service treatment records show in a February 1968 RA report of physical examination the Veteran reported a history of recurrent back pain. On examination his spine was evaluated as normal. The Veteran was treated for back strain in July 1968, with onset of pain two weeks earlier. In January 1969 the Veteran reported having back pain for years. While on ETS examination in December 1970, the Veteran reported a history of recurrent back pain, on examination his spine was evaluated as normal. As such, the service treatment records lack the combination of manifestations sufficient to identify a chronic back disability as distinguished from merely isolated findings. Rather, the record suggests that the in-service back complaints resolved with treatment. The Board finds that the service treatment records lack sufficient observation or even notation to establish any disability onset in service. After service, private treatment records in June 1993 show treatment for low back pain associated with an industrial injury incurred in February 1993. The Veteran endorsed a history of prior back symptoms. On examination in connection with a disability claim in September 1993, the clinician noted a history of back injury in February 1993 in the course of his employment. The Veteran denied any previous industrial injuries or severe back symptoms, however, he reported intermittent low back pain and stiffness for the preceding four to five years. Based on the Veteran's report of prior symptoms, the clinician determined that there was a pre-existing mildly symptomatic degenerative disc disease that accounted for 20 percent of the Veteran's disability, while the remaining 80 percent was attributed to the recent occupational injury. On VA examination in July 1996, the Veteran reported having last been employed in 1993, at which time he experienced difficulty with his back and hips. Reportedly, when the Veteran was examined in 1993, he was told at that time that he had a bulging disc at L5-S1 and some osteoarthritis at L4-L5. A private treatment record in May 2002 noted a history of chronic low back pain following an injury in 1993. VA treatment records after 2003 show treatment for low back pain. In September 2003 the Veteran reported a history of back pain for 10 years due to falling from a ladder. Regarding chronicity, even when considering the Veteran's competent and credible report of back problems in service, and in light of the fact that he was awarded the Parachutist Badge, the evidence still does not support a finding of continuity of symptomatology for arthritis of the spine or any other back disability. After service, the next record of treatment for a back disorder is not until 1993, when the Veteran was seen for complaints related to an occupational injury in 1993, more than 20 years after discharge from service. As such, this evidence factors against the Veteran's claim. That is, the resolved in-service complaint, the prolonged period without complaint or treatment for low back pain at least until 1993, and the lack of clinical findings relating to the back until 1993, all factor against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). As noted, the initial radiographic documentation of degenerative changes of the spine is well beyond the one-year presumptive period for manifestation of arthritis, service connection cannot be established for arthritis of the spine on a presumptive basis. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). Service connection for arthritis is not warranted on a presumptive basis as a chronic disease. On the question of medical causation, there is no probative medical evidence that supports the claim. The Board notes that there are outstanding medical questions in this case. As previously noted, however, the Veteran has failed to report for VA examinations which could have yielded the medical opinions needed for full understanding of his disability and its etiology. The Veteran was scheduled for a VA examination in April 2013, but he failed, without good cause, to report for the scheduled examination. As a result, the Board must come to a determination solely on the basis of information included in the record. 38 C.F.R. § 3.655 (2013). The Board reiterates that the duty to assist is not a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). Governing regulation provides that when a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. In this case, the evidence of record does not contain information pertinent to the question of whether his back disorder is related either to service or a service-connected disability. Although the Veteran was provided with the opportunity to obtain such medical opinion, he did not avail himself of this opportunity, and consequently, VA is left without a complete record to adjudicate his claim. The Veteran has submitted medical articles/treatise evidence in support of his claim. However, the record does not contain competent and credible evidence as to whether the Veteran's particular back disability is related to service or service-connected disability. In fact, the most probative medical evidence associates the Veteran's low back disability with a post-service occupational injury in 1993, and no other medical evidence links his back problems to service in any way. The Board recognizes the Veteran's contentions as to the diagnosis of a back disability and its relationship to service. The Veteran is competent to report about what he experienced; however, as to the specific issue in this case, the diagnosis of degenerative changes of the spine, and its etiology are not subject to lay observation or assertion, and fall outside the realm of common knowledge of a lay person. The diagnosis was based on clinical findings, to include radiographic studies, and is medical in nature. Due to the medical complexity of the issues involved, the Veteran's assertions alone are insufficient to establish service connection. As a lay person, the Veteran has not been shown to be qualified through education, training, and expertise to offer an opinion on a medical diagnosis or on medical causation. Thus, his lay assertions are of little, if any, probative value when offered to establish a causal connection between his back disability and service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Moreover, whether the symptoms the Veteran reportedly experienced in service or following service are in any way related to his current back disability is also a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the onset and etiology of his current back disability is not a competent medical opinion. In summary, the most probative evidence shows that a chronic back disability was not shown in service or for many years after service, and is not otherwise related to active service. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Hypertension The Veteran seeks entitlement to service connection for hypertension, to include as secondary to the Veteran's service-connected diabetes mellitus. The service treatment records documented a blood pressure reading of 138/84 on RA examination in February 1968. The service treatment records contain no complaint, history or findings consistent with hypertension. As hypertension was not diagnosed in service, an onset or chronicity in service is not established. After service, 1993 private treatment records for a back disorder documented hypertension. On VA examination in July 1996, the Veteran reported taking medication for hypertension. Reportedly, he had been found to be hypertensive following blood work some time in 1991 or 1992. The examiner noted intermittent hypertension, not present on examination. VA treatment records starting in 2003 contain a diagnosis of benign hypertension. The Board acknowledges that hypertension is considered a "chronic" disability. However, the theory of continuity of symptomatology is only required when the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). As previously noted, hypertension was not noted in service. Additionally, none was noted within the presumptive period post service. The evidence also does not support a finding of continuity of symptomatology associated with elevated blood pressure. After service, the next record of treatment for high blood pressure is not until approximately 20 years after discharge from service. This evidence weighs against the Veteran's claim. That is, the prolonged period without complaint or treatment, and the lack of clinical findings relating to high blood pressure until at least 1991, factors against the claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). As noted, the claims file contains no reference to treatment for elevated blood pressure or hypertension until 1993, with a historical reference to 1991. As such, service connection cannot be established for hypertension on a presumptive basis. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). To the extent that the Veteran asserts continuity of hypertension symptomatology since service, the Veteran's statements are not competent. The Veteran, as a layperson, is competent to describe symptoms that he has experienced. Layno v. Brown, 6 Vet. App. 465 (1994). However, due to the complexity of the disease at issue, the Veteran is not competent to diagnose his disease or attribute any symptoms to this complex disease. Hypertension is not a condition where lay observation has been found to be competent to establish a diagnosis or the presence of the disability. The determination as to the diagnosis or presence of the disability is medical in nature and not capable of lay observation. Although lay evidence may establish a diagnosis of certain medical conditions, such as a simple medical condition, hypertension is not a simple medical condition. The diagnosis requires diagnostic testing and medical evaluation to identify, which a lay person is not qualified to do. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To the extent the Veteran contends that his hypertension is related to service, the Board finds the medical evidence of record to be more probative of such a relationship than the lay contentions of the Veteran. Due to the medical complexity of the issues involved, the Veteran's assertions alone are not sufficient to prove that the condition manifested, was treated, or was diagnosed within one year of service discharge. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that the statements from the Veteran offered as proof of service connection between hypertension and service are not competent evidence. Rather, the objective evidence of record is of greater probative value than the Veteran's assertions. The objective evidence of record shows that the Veteran's hypertension did not have its onset in service or within a year after service; rather, it shows that it was initially diagnosed numerous years post service and is in no way related to service. Significantly, there is no competent evidence of record relating hypertension to military service. In fact, aside from the Veteran's contentions, the record contains no evidence suggesting that his hypertension may somehow be due to military service. Again, the Veteran failed to report for an additional VA examination that may have yielded pertinent evidence. Finally, to the extent that the Veteran reports that he developed hypertension secondary to the service-connected diabetes mellitus, the probative medical evidence does not support the claim. On VA diabetes mellitus examination November 2008, the examiner noted a past medical history of hypertension since the 1990's. While the Veteran was asymptomatic, he was diagnosed with diabetes mellitus during a routine checkup in August 2008. The examiner diagnosed essential hypertension, under treatment, and opined that the Veteran's hypertension was not caused by, secondary to, or aggravated by diabetes mellitus. The examiner based the opinion on the fact that hypertension preceded diabetes mellitus by at least 10 years. Additionally, his BUN, creatine and microalbumin were normal. There is no contradictory medical evidence of record. The VA examiner's opinion is both competent and credible and, therefore, probative. The opinion is well reasoned, detailed, consistent with the other evidence of record, and included consideration of the relevant history. Prejean v. West, 13 Vet. App. 444 (2000). Based on the foregoing, the probative and persuasive evidence does not show that hypertension was caused or aggravated by active duty service or service-connected disability. Hypertension did not manifest in service, to a compensable degree within one year of separation from active duty service, and it is unrelated to a disease, injury, or event during service, or to a service-connected disorder, to include diabetes mellitus. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Gastrointestinal Problems Although on discharge examination in December 1970, the Veteran reported a history of stomach, liver or intestinal trouble, his gastrointestinal system was evaluated as normal. The service treatment records contain no complaint, history or findings consistent with gastrointestinal problems or a disability manifested by chemical imbalance. After service, on VA examination in July 1996, the Veteran denied a history of remarkable gastrointestinal symptoms. On VA diabetes mellitus examination, the examiner noted a past medical history of gastroesophageal reflux disease since 1998. When examined, there were no findings reported for the Veteran's gastrointestinal system and a diagnosis consistent with a gastrointestinal disorder was not recorded. After service, VA and private medical records generally document treatment for various disorders. The reports also contain an assessment of gastritis. As previously noted, the Veteran was scheduled to appear at a VA stomach and duodenal disorders examination in April 2013. While the VA examination may have yielded pertinent findings in this regard, the Veteran failed, without explanation, to report to that examination. Hence, the Board has no alternative but to evaluate the claims on the basis of the evidence of record and as indicated, this evidence simply is not supportive of the claim for service connection. The Veteran's complaints are acknowledged, as well as the notation of gastritis. Nonetheless, there is no probative evidence of record demonstrating that the Veteran's gastrointestinal disorder, to include gastritis, had its onset in service or is in any way etiologically related to active duty service. The service treatment records in this regard show normal findings and the post service evidence fails to suggest a nexus between the Veteran's current disorder and service, any event of service, and any service-connected disability. To the extent that the Veteran may complain of gastrointestinal problems and asserts that he has had such complaints since service or that they are attributable to his service-connected disability, the Board finds that the Veteran's statements are not competent. The Veteran, as a lay person, is not competent to render a diagnosis and attribute it to any event of service or any service-connected disability. As a result, his assertions do not constitute evidence sufficient to establish a causal nexus. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994); 38 C.F.R. § 3.159(a)(2) (2013). In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Chemical Imbalance The service treatment records contain no complaint, history or findings consistent with a disability manifested by chemical imbalance. A May 2007 VA clinical treatment note reflects the Veteran's report that he was once told that he had a chemical imbalance. VA and private medical records generally document treatment for various disorders (such as for the service-connected diabetes mellitus), but not a disability manifested by a chemical imbalance. As previously noted, the Veteran failed to report for a VA examination in April 2013. While the VA examination may have yielded a medical diagnosis of other pertinent findings in this regard, the Veteran failed, without explanation, to report to that examination. Hence, the Board has no alternative but to evaluate the claims on the basis of the evidence of record and as indicated, this evidence simply is not supportive of the claim for service connection. Since filing his claim for service connection in April 2007, the Veteran does not have diagnoses of a disability manifested by chemical imbalance. To the extent that the Veteran may complain of symptoms he attributes to a chemical imbalance, complaints of symptoms alone, without a diagnosed or identifiable underlying malady or condition, do not constitute a disability for which service connection may be granted. See generally, McClain v. Nicholson, 21 Vet. App. 319 (2007); Degmetich v. Brown, 8 Vet. App. 208 (1995) (compensation may only be awarded to an applicant who has a disability existing on the date of the application, and not for a past disability); Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) (pain, alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted); Brammer v. Derwinski, 3 Vet. App. 223 (1992) (in the absence of proof of the claimed disability, there can be no valid claim). Here, the preponderance of the evidence of record is against a finding of any current diagnosis of a chemical imbalance. The Board recognizes the Veteran's contention that service connection should be granted for a chemical imbalance. As a layperson, however, he is not competent to provide an opinion requiring medical knowledge, such as a diagnosis of a disability resulting from a chemical imbalance. As a result, his assertions do not constitute medical evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994); 38 C.F.R. § 3.159(a)(2) (2013). In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, is denied. Service connection for substance abuse is denied. Service connection for a back disability is denied. Service connection for hypertension is denied. Service connection for gastrointestinal problems is denied. Service connection for chemical imbalance is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs