Citation Nr: 1723914 Decision Date: 06/23/17 Archive Date: 06/29/17 DOCKET NO. 08-12 061 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for an acquired psychiatric disorder (other than posttraumatic stress disorder). REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Taylor, Associate Counsel INTRODUCTION The Veteran served on active duty in the Army from November 1977 to March 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions. In August 2000, the Regional Office (RO) in Montgomery, Alabama denied reopening the claim for degenerative disc disease (DDD) of the spine. In May 2004, the Columbia, South Carolina RO denied service connection for DDD of the lower spine. In May 2006, the RO in Atlanta, Georgia denied service connection for depression, with anxiety. These matters are currently under the jurisdiction of the RO in Montgomery, Alabama. Notices of Disagreement were filed in November 2000, May 2005 and June 2006. Statements of the Case were issued in July 2006 and March 2008. A substantive appeal, VA Form-9 was filed in June 2006 and April 2008. Supplemental Statements of the Case were issued in August 2014 and March 2015. In May 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). The transcript of the hearing is of record. The Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for further development in June 2016. The appeal is now before the Board for further appellate action. As a preliminary matter, the Board acknowledges that in June 2013 the RO issued a formal finding of unavailability of the Veteran's service medical records after requesting a search of the National Personnel Records Center (NPRC). Only the Veteran's July 1977 entrance examination report, dental records and his March 1989 separation examination report are associated with the claims file. In a case where the Veteran's service medical records are unavailable through no fault of his own, there is a heightened obligation for VA to assist him in the development of his claim. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The heightened duty includes an obligation to search for alternative medical records which might verify the Veteran's statements. Moore v. Derwinski, 1 Vet. App. 401 (1991). Alternate sources of evidence may be used in a claim where there are missing records. Those sources include statements from service medical personnel; buddy statements; employment physical examinations; medical evidence from hospitals and clinics; evidence from private physicians who may have treated the claimant, especially soon after separation; and letters written during service. VA has requested that the Veteran provide all outstanding medical records and/or assist VA in obtaining the records. As such, all known pertinent medical records have been associated with the claims file. The Board may proceed with adjudicating the current appeal without prejudice to the Veteran. The Board reviewed the Veteran's electronic claims file which includes records in Virtual VA and Veterans Benefits Management System (VBMS) databases prior to rendering its decision. FINDINGS OF FACT 1. The most probative evidence of record shows that a low back disorder was not manifested during or as a result of active military service. 2. The most probative evidence of record shows that an acquired psychiatric disorder, (other than posttraumatic stress disorder) was not manifested during or as a result of active military service. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a low back disorder have not been met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2016). 2. The criteria for establishing service connection for an acquired psychiatric disorder (other than posttraumatic stress disorder) have not been met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 4.125, (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits under the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the Veteran's claims for service connection, the Veteran was provided appropriate VCAA notice in March 2006. The record reflects that the Veteran has had a meaningful opportunity to participate in the adjudication of the claim, including presentation of testimony at the May 2011 hearing such that the essential fairness of this adjudication is not affected. Relevant to the duty to assist, the Veteran's available service treatment and personnel records, VA and private treatment records, and VA examination reports have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In June 2016, the Board remanded the case for additional development, to include obtaining VA, private and prison medical treatment records, to obtain an addendum medical opinion to the February 2015 VA mental condition examination, and to notify the Veteran that VA was unable to obtain all of his service treatment records (STRs). The Board finds that the RO has substantially complied with the remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). II. Service Connection Legal Criteria Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if preexisting such service, was aggravated thereby. 38 U.S.C.A. §§ 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303(a). Generally to establish entitlement to service connection, a Veteran must show evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease. All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Alternatively, under 38 C.F.R. § 3.303 (b), service connection may be established for certain chronic diseases listed under 38 C.F.R. § 3.309 (a) by either (1) the existence of such a chronic disease noted during service, or during an applicable presumption period under 38 C.F.R. § 3.307, and present manifestations of that same chronic disease; or (2) where the condition noted during service is not in fact shown to be chronic or where the diagnosis of chronicity can be legitimately questioned, then a showing of continuity of symptomatology after discharge is required to support the claim of service connection. 38 C.F.R. § 3.303 (b) (2016); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 469; see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ('although interest may affect the credibility of testimony, it does not affect competency to testify'). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived or experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F. 3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a lay person is competent to identify the medical condition; he is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). As in the instant appeal, where the service records are incomplete, the obligation to explain findings and conclusions and to consider carefully the benefit-of-the-doubt rule is heightened. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). But, this does not lower the threshold for an allowance of a claim, for example where the evidence almost but not quite reaches the positive-negative balance. In other words, the legal standard for proving a claim is not lowered; rather, the obligation to discuss and evaluate evidence is heightened. Russo v. Brown, 9 Vet. App. 46 (1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107 (b). III. Factual Background and Analysis Low Back Disorder The Veteran seeks service connection for a low back disorder as a result of his military service. The Veteran has a current low back disability, but the most persuasive evidence of record is against a finding that the Veteran's low back disorder is related to service. On entrance to service in July 1977, the Veteran's clinical evaluation was normal. On his separation report of medical history in March 1989, the Veteran reported that his health was fair and endorsed yes for recurrent back pain. A complaint of lower back pain was also noted. He denied any problems related to recurrent back pain or any back injury. He also denied wearing a back brace or support. The Veteran did complain of certain ailments on separation, including problems related to, but not limited to, dizziness/fainting spells, ear, nose or throat trouble, severe tooth or gum trouble and stomach, gastrointestinal problems. The clinical evaluation at separation also noted that the Veteran's spine was normal. Treatment records indicate that the Veteran complained of back pain while incarcerated in September 1993 at the Georgia Department of Corrections. An October 1996 VA treatment record indicates that the Veteran had a history of low back pain. Physical examination revealed tenderness in the lower lumbar and sacral area and that the Veteran denied a history of a fall or trauma to his back. An April 2001 VA treatment record indicates a diagnosis of degenerative disc disease of the lumbar spine. The Veteran was treated for chronic pain associated with DDD of the lumbar spine beginning in November 2000 until the present. During a May 2001 mental health consultation, the Veteran reported that he injured his back twice while "picking up huge pots of water." A March 2005 Central Alabama VHCS report indicates that the Veteran reported pain related to DDD in the cervical and lumbar spine, a diagnosis of degenerative arthritis in the cervical and lumbar spine and chronic pain since 1990. The Veteran reported two episodes of severe lumbar spasms while in service. May 2004 x-ray findings revealed cervical DDD and spondylosis of the cervical spine with neural foramina encroachment at L5-L7. The lumbar spine showed mild loss of statures of vertebral bodies at L4-L5 and DDD at L5-S1. In a June 2005 Statement of the Case, the Veteran claimed that while on active duty he was given 2 separate profiles for severe muscle spasms of the lower back with restrictions of lifting more than 25 pounds and no prolonged standing. The Veteran stated that he has continuing back problems since receiving the 2 in-service profiles. The Veteran contends that his diagnosed DDD is the same condition for which he was given the profiles on active duty. In an August 2007 Statement in Support of Claim, the Veteran revealed that he was in a 1983 motor vehicle accident. At his May 2011 hearing, the Veteran testified that he was placed on 2 (2-week) profiles during service for severe back pain. He was restricted from prolonged standing and lifting more than 25 pounds. The claimed injuries occurred while the Veteran was stationed in Germany and the Czech Republic. The Veteran also testified that he has severe arthritis and interrupted sleep that causes depression. The Veteran testified that he receives SSA benefits. The Board notes that the Veteran receives SSA benefits for discogenic and degenerative back disease. The Veteran was afforded a VA back examination in July 2013. The Veteran was diagnosed with DDD of the lumbar spine at L5-S1, spondylisthesis at L3-L4. The medical report indicated flare-ups with functional loss and limited range of motion (ROM). Forward flexion was 90 degrees, extension 30 degrees, right lateral flexion 30 degrees, left lateral flexion 30 degrees, right lateral rotation 30 degrees and left lateral rotation was 30 degrees. The Veteran experienced excess fatigability but no tenderness or pain on palpation of the soft tissue of the thoracolumbar spine. The examiner opined that it was less likely as not that the Veteran's low back disorder was incurred in or caused by his military service. The rationale being that the examiner did not find any document of an injury or disease that caused the Veteran's low back disorder in service or within one year of separation. The Board remanded the appeal in November 2014 for an addendum medical opinion. The Board found the opinion inadequate because the examiner based his medical opinion solely on his inability to find any documentation of a low back disorder in service or within a year following service. The Board determined that an examiner may not ignore lay evidence and base his/her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The Veteran claims that he had 2 (2- week) profiles in service related to muscle spasms of the lower back, including one that occurred after trying to raise a pot of water. The Board notes that the Veteran was an E-3 Food Service Specialist. See Certificate of Release or Discharge from Active Service, Form DD-214. A July 2015 lumbar x-ray revealed DJD with mild changes of spondylosis, forward listhesis of L3-L4. A February 2015 VA examination indicates that the Veteran has degenerative arthritis of the spine. The Veteran revealed that his low back pain has worsened over the years. The Veteran contends that his lower back disorder is related to service, specifically two severe muscle spasms to the lower back as a result of lifting heavy pots, jumping off of heavy trucks, which can range from a three to four foot drop, while carrying "stuff" on his back. He related the muscles spasms to his two profiles in service. The Veteran experienced flare-ups, evidence of pain with weight bearing, decreased ROM and muscle spasms. Forward flexion was 40 degrees, extension 15 degrees, right lateral flexion 20 degrees, left lateral flexion 20 degrees, right lateral rotation 20 degrees, and left lateral rotation 20 degrees. Pain was noted on examination but did not result in functional loss. The Veteran had localized tenderness or pain on palpation of the soft tissue of the thoracolumbar spine. According to the examiner, it is less likely than not that the Veteran's lower back disorder is a result of service. The rationale being that there was no medical evidence or documentation to suggest that the Veteran's lower back disorder was related to his treatment of muscle spasms during service. The examiner considered the Veteran's military occupational specialty (MOS) and that it required heavy lifting. The examiner further opined that the Veteran's lower back disorder did not develop to a compensable degree within one year of separation. The Veteran complained of back pain in 1993 and was diagnosed with lumbar DJD with spondylosis in 1995. In 2000, per orthopedic notes, the Veteran suffered from cervical strain but a normal lumbar spine was noted. The examiner opined that literature shows that the natural degeneration that accompanies the aging process is the primary cause of degenerative joint disease. A November 2015 MRI revealed lower predominant advanced degenerative disc disease, most severe at L4-L5 and L5-S1 and stable grade 1 anterolisthesis of L3-L4. July 2016 VA treatment notes indicate worsened chronic back pain. The existence of a present disability is established through the Veteran's medical treatment records and examination reports produced during the course of his appeal. These records contain a diagnosis of DDD of the lumbar spine. The remaining inquiry is whether the evidence demonstrates the incurrence of a chronic low back disorder in service or as a result of service. Upon review of the foregoing evidence, the Board concludes that the evidence of record is against a finding that the Veteran's low back condition is related to his military service. Here, the February 2015 VA examiner's conclusions are shown to have been based upon a review of the Veteran's claims file, including service entrance and separation examination reports, and VA treatment records; a physical examination; and the Veteran's statements regarding the onset of his symptoms. Moreover, the VA opinion is accompanied by a sufficient explanation and reference to pertinent evidence of record. The conclusion is consistent with the evidence of record, including the service separation examination record showing recurrent back pain but no treatment for a low back disability during the Veteran's period of active duty. In the precedent decision of Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), the Court held that the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion. In this case, the examination report and opinion provided by the VA examiner in February 2015, provides a solid basis for the opinion provided, with sound reasoning and conclusions. Given this, it is afforded great probative weight. The Board acknowledges the Veteran's assertions that his low back disorder is due to service. Lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). In addition, the Veteran's Form DD-214 indicates that he served as a Food Service Specialist during active duty which requires heavy lifting. He also testified to heavy lifting and jumping from trucks 3 to 4 feet from the ground with "stuff" in his hands. The Veteran contends that his low back disorder is a result of his MOS. The Board recognizes that competent medical evidence can be provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159 (a)(1). Thus, the Board affords little probative weight to the Veteran's opinion that his low back disorder is related to his period of service, to include the physical demands and rigors of his MOS on active duty. See Mattke v. Deschamps, 374 F.3d 667, 670 (8th Cir. 2004) (providing that a diagnosis by laboratory testing is distinctly not within the realm of common lay knowledge). However, the Board notes that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). When reviewing medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). In light of this, the Board has carefully considered the Veteran's opinion regarding the etiology of his low back disorder, but ultimately finds that the VA examiner's opinion is afforded more probative weight compared to the Veteran's opinion. As noted, the VA examiner's opinion rested on a review of the entire claims file in addition to the examination of the Veteran and diagnostic testing. Mattke, supra. In addition, the VA examiner is a physician and the Veteran does not possess the expertise to provide him with the same level of experience and medical knowledge as a physician. The Veteran also did not provide any more information or evidence in support of his opinion, other than his contentions and the fact the he had 2 (2-week) profiles during service, nor did he provide a thorough rationale based on sound medical principles. A medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As demonstrated in this appeal, the mere fact of an in-service injury is not enough. Rather, there must be a chronic disability resulting from that injury. Any manifestation of low back muscle spasms and/or low back pain in-service does not necessarily permit service connection of a low back disorder shown as a clear cut clinical entity at some later date. See 38 C.F.R. § 3.303(b). The VA examiner found that there is insufficient probative evidence to link the Veteran's current low back disorder to symptoms he contends he experienced in service. Accordingly, service connection is not warranted on a direct basis. The Board also notes that the Veteran has asserted that he had problems with his low back in service and after service. However, the objective clinical evaluations at separation found the Veteran's spine to be normal and VA treatment records beginning from 1996 did not reflect that the Veteran began to seek consistent treatment for low back pain. The Board notes that the absence of documented treatment cannot be the sole basis for finding an uncorroborated statement non-credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In this regard, the Board notes that the Veteran sought treatment for other complaints and problems after service and was given ample opportunity to report any problems related to his low back pain during service in the years following service. The Veteran did not seek treatment for a low back disorder and/or low back pain after separation until 1993 while incarcerated in the Georgia Department of Corrections, approximately 4 years after separation. The most probative evidence of record indicates that the Veteran's diagnosed DDD of the lumbar spine did not manifest to a compensable degree within the one year presumptive period after separation. Thus, the current lay statements are found to lack credibility because they are inconsistent and directly contradicted by other medical evidence of record. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Calusa v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). Based on the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran's currently diagnosed low back disability is warranted on a presumptive basis and must be denied. In reaching the above conclusions, 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 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, supra. Psychiatric Disorder The Veteran seeks service connection for an acquired psychiatric disorder (other than posttraumatic stress disorder) due to his military service. STRs document that upon service entrance examination in November 1977, the Veteran was evaluated as psychiatrically normal and he denied any mental health symptoms. He was again evaluated as clinically normal psychiatrically in March 1989 and signed a statement that he "was in fair health." On the separation report of medical history, the Veteran endorsed depression or excessive worry and nervous trouble of any sort. The separation report of mental status evaluation deemed the Veteran psychiatrically normal. In October 1997, the Veteran had a VA mental health consultation. In June 1999, the Veteran did not complete an in-patient VA alcohol and drugs treatment program. The Veteran has sought treatment for depression, anxiety and substance abuse and reported intermittent homelessness since June 2000 to the present. The Veteran was diagnosed with major depressive disorder, bipolar disorder, substance dependence (alcohol, cocaine, cannabis) in April 2001. He was also admitted to the Primary Care Substance Abuse Clinic but did not complete the treatment program. A July 2002 private treatment record indicates that the Veteran attempted suicide. A March 2005 Central Alabama VHCS report indicates that the Veteran completed a 4-month substance abuse treatment problem in March 2004. The Veteran reported a history of paranoid fear and auditory hallucinations with onset in his early twenties. Recurrently provided a report of depression and was diagnosed with a schizoaffective disorder, depressive type; adjustment disorder due to chronic pain. The clinician noted, that in 2001 the Veteran had four psychiatric admissions and since then admissions in 2002, 2003 and 2004. In Sept 2005, the Veteran was diagnosed with a mood disorder, schizoaffective disorder, cocaine abuse, and was hospitalized for a substance abuse problem, suicidal ideation and plan. The Veteran claimed, in a June 2006 NOD, that he was treated for depression in 1984 at Ft. Benning, Georgia; in 1985 received treatment for anxiety/depression-related behavior at Erlangen, Germany; in 1994 attempted suicide, was admitted to the West Central Mental Hospital (60-day stay); in March 2002 was diagnosed with paranoid schizophrenia; attempted suicide in 2005 and was admitted to Tuskegee VAMC mental ward (8-day stay). The Veteran testified at the May 2011 hearing that he has severe arthritis and interrupted sleep that causes his depression. The Veteran testified that he "basically break[s] down... [and] gets deeper and deeper...into depression." The Veteran testified that he experiences nervousness, fidgeting, and needs to move. The Veteran testified that he has "problems being around people with depression anxiety because of his pain." The Veteran received mental health treatment on several occasions since diagnosed with a depressive disorder, including inpatient treatment in October 2012. The Veteran was admitted to the Domiciliary Rehabilitation Treatment Program, a 91-day program for substance abuse treatment, in November 2012. In February and March 2013, July 2014, March, June, July, and November 2015, the Veteran was treated for depression and/or mental health and substance abuse problems. In July 2013, the Veteran was afforded a VA mental disorder examination. The claims file was reviewed in addition to an in-person examination. The Veteran was diagnosed with depressive disorder, NOS (Axis I). The examination report indicates that the Veteran's depression is related to his back and/or neck problems and that his anxiety appears secondary to depression. A secondary diagnosis of anxiety was not warranted. The examiner found that such diagnosis was unrelated to the Veteran's service. He cited the Veteran's history of mental health treatment that began in the 1990s, alcohol and substance abuse/dependence, intermittent inpatient admissions due to depression (related to back pain) and 3 reported suicide attempts. The examiner found it at least as likely as not that the Veteran's depressive disorder is not related to the Veteran's low back condition. The rationale being that the Veteran appears to be a credible historian. The examiner considered the chronology of symptoms onset and progression of symptomatology, consistency of treatment modalities with symptomatology and the diagnosis claimed. The November 2014 Board remand required an addendum opinion. The Board observed that the July 2013 examiner failed to address the question of whether the Veteran has an acquired psychiatric disorder directly due to service. The Board required an addendum opinion for medical guidance on whether any currently diagnosed psychiatric disorder is causally linked to, or can be associated with the Veteran's period of active service. In February 2015, the Veteran was afforded a VA examination. The Mental Disorders DBQ indicated that the Veteran has major depressive disorder that conforms with DSM- 5 criteria. The examination report indicates that the Veteran was diagnosed with schizophrenia and bipolar disorder in the past but the only current mental health condition being treated is that of depression. The Veteran was not treated for his mental health diagnosis until 2001.The examiner concluded that the Veteran's current condition is not due to or caused by his military experience. In June 2016, the Board remand required an addendum medical opinion. The AOJ did not obtain an addendum medical opinion, but scheduled the Veteran for a new VA examination that the Veteran failed to report to. In July and September 2016, the VA provided addendum medical opinions as to whether the Veteran's depressive disorder is related to his military service. According to the examiner, it is less likely than not that the Veteran's depressive disorder was incurred in or caused by the claimed in-service injury, event or illness. The examiner opined that he cannot assert that the Veteran's current depressive symptoms are as likely as not caused by or are a progression of mood symptoms he exhibited during service. The rationale being that the origin of the Veteran's depression is unclear as evidenced by past diagnoses of major depressive disorder, schizoaffective disorder, bipolar disorder, and mood disorder related to pain. The differences between these diagnoses and the differences in behavior problems they imply are not insignificant. The examiner further opined that review of the record revealed diagnoses of cannabis abuse, alcohol abuse, and cocaine induced mood disorder as recent at July 2016 at the conclusion of the Veteran's most recent psychiatric admission. The examiner opined that concurrent polysubstance abuse played a significant or even a dominant role in the Veteran's pattern of mood symptoms and perhaps his psychotic episodes. The evidence of record indicates that the Veteran continues to seek treatment for his depressive disorder and polysubstance abuse. The Board finds that service connection on a direct basis for an acquired psychiatric disorder is not warranted. Furthermore, the Board notes that a psychiatric disorder was not manifested to a compensable degree within one year following discharge from service. Accordingly, service connection on a presumptive basis is not warranted. In making such finding, the Board accords great probative weight to the September 2016 VA examiner's opinion. In this regard, the September 2016 VA examiner found that the origin of the Veteran's depressive disorder is unclear as evidenced by past diagnoses of major depressive disorder, schizoaffective disorder, bipolar disorder, and mood disorder related to pain. The Veteran's chronic cannabis abuse, alcohol abuse, and cocaine induced mood disorder played a significant or even a dominant role in the Veteran's pattern of mood symptoms and perhaps his psychotic episodes. The persuasive evidence of record indicates that the Veteran's depressive disorder is not related to service but has a nexus or relationship with his chronic alcohol and substance abuse. In reaching his conclusion, the September 2016 VA examiner considered the Veteran's lay and clinical history, to include available service and post-service records and examination results, as well as on specialized clinical experience and knowledge. Accordingly, this evidence is considered both competent and highly probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Therefore, the Board finds no adequate basis to reject this competent medical opinion based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In addition, the Veteran has not provided any competent medical evidence or credible lay reports to rebut this opinion or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). The Board has also considered the Veteran's assertions that his depressive disorder is related to service. The Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau, 492 F.3d at 1377). In this case, the causes of the Veteran's depressive disorder involves a complex medical etiological question, requiring specific, specialized, medical knowledge and training that the Veteran is not shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (holding that ACL is too "medically complex" for lay diagnosis based on symptoms); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a disorder capable of lay diagnosis). Thus, the probative evidence does not show the Veteran's acquired psychiatric disorder, to include a depressive disorder, to be etiologically or causally related to his military service, or that psychosis manifested to a compensable degree within one year from his service discharge. The Veteran endorsed depression or excessive worry and nervous trouble of any sort on his March 1989 separation examination report. However, the record evidence indicates that he did not seek mental health treatment until October 1997, several years after separation. In June 1999, the Veteran did not complete an in-patient VA alcohol and drugs treatment program. Furthermore, the Veteran was diagnosed with major depressive disorder, bipolar disorder, substance dependence (alcohol, cocaine, cannabis) in April 2001, approximately 10 years after separation. The September 2016 medical opinion that associates the Veteran's depressive disorder with his post-service substance abuse diagnosis is highly probative and persuasive to the issue at hand. For the foregoing reasons, the Board finds that service connection for an acquired psychiatric disorder, to include a depressive disorder (other than posttraumatic stress disorder) must be denied. 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 claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102 ; Gilbert, supra. ORDER Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for an acquired psychiatric disorder (other than posttraumatic stress disorder) is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs