Citation Nr: 1752763 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 12-23 245 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for acquired psychiatric disability, to include bipolar disorder and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Robert Chisholm, Attorney ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1962 to September 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The Board previously denied this matter in March 2015. Subsequently, the decision was appealed to the United States Court of Appeals for Veterans' Claims (Court/CAVC), and a November 2015 Court Order granted a Joint Motion for Remand (JMR), which vacated the Board's decision and remanded it for further development. Specifically, the Court found the November 2009 VA examination had inadequate rationale. In January 2016, the Board remanded the claim in order to obtain an addendum opinion in compliance with the November 2015 JMR and Court order. The case has now returned to the Board for further appellate review. FINDINGS OF FACT 1. The most probative evidence of record establishes that the Veteran does not currently meet the criteria for a current diagnosis of PTSD. 2. The most probative evidence of record establishes that the Veteran's Bipolar Disorder is not etiologically related to his reported in-service stressors. CONCLUSION OF LAW The criteria to establish service connection for an acquired psychiatric disorder, to include PTSD and Bipolar Disorder, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304(f) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Veteran's service treatment records are unavailable. In such cases, the Board has a heightened duty to assist and obligation to explain its findings and conclusions and to carefully consider the benefit of the doubt rule. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The legal standard, however, for proving a claim for service connection is not lowered, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. Russo v. Brown, 9 Vet. App. 46 (1996). There is no adverse presumption of service connection as a result of the loss of these records. Cromer v. Nicholson, 455 F.3d 1346 (Fed. Cir. 2006). In this case, the Veteran's lay assertions were given further consideration by various VA examiners in compensating for the missing records. Service Connection - Applicable Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish the service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed aggravation of a disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection for a psychiatric disorder, to include PTSD requires the following three elements: (1) a current medical diagnosis of a psychiatric disorder, to include PTSD, (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f). In adjudicating a claim for service connection for a psychiatric disorder, to include PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a); 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran "engaged in combat with the enemy." Id. If VA determines that the veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran's lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f). No further development or corroborative evidence is required, provided that the claimed stressor is "consistent with the circumstances, conditions, or hardships of the veteran's service." Id. If, however, VA determines that the veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the veteran's lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran's testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of a psychiatric disorder, to include PTSD is a question of fact for medical professionals and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. The law provides that, if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Gallegos v. Peake, 22 Vet. App. 329 (2008). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(3). Additionally, under 38 C.F.R. § 3.304(f), VA can submit any evidence, including alternate source evidence, to a medical or mental health professional for interpretation. Bradford v. Nicholson, 20 Vet. App. 200 (2006). Most significantly, for claims involving an in-service personal assault, after-the-fact medical evidence can be used to establish a stressor. See Bradford v. Nicholson, 20 Vet. App. 200 (2006); Patton v. West, 12 Vet. App. 272, 278 (1999). 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 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 v. Brown, 6 Vet. App. 465, 469 (1994); 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"). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Factual Background As noted above, the Veteran's service treatment records are unavailable. A formal finding of unavailability was associated with the record on February 14, 2012. Post-service records from Mayview State Hospital note that the Veteran was admitted in March 1978 under a commitment as a transfer from another hospital, where, during the admission process, he had attacked a doctor. His wife stated that his behavior had become erratic and irrational a few days prior to admission. He was admitted because of bizarre behavior and speech, and extreme assaultiveness. His progress was rapid with psychotropic medication. He had a number of personal and financial problems which had begun during 1977. It was noted that he denied any prior psychiatric hospitalizations. He was discharged after nine days of hospitalization with a diagnosis of schizophrenia, paranoid type, acute, in excellent remission. He was to follow up with the medications Haldol and Cogentin. VA medical records dated February 1986 show that the Veteran was again hospitalized for treatment of Bipolar Disorder, manic. According to a psychiatric review dated in March 1993, he had a rather long psychiatric history dating back to 1978 when he was first hospitalized for severe mood disorders. Subsequently, he had at least three inpatient treatments, most recently in February 1986. He had been treated as an outpatient since then, doing fairly well with continuous medication. In November 2009, the Veteran underwent a VA examination, which also included psychological testing. The Veteran said that after service, he did not report any psychiatric problems or treatment until around 1977, when he went to a facility because he was hearing voices. The examiner noted that he had been consistently maintained on psychiatric medications since the 1970's. It was noted that the Veteran had never engaged in individual or group counseling or psychotherapy, and he had never been diagnosed with PTSD by any of his providers. His PTSD screens had been negative, and there were no symptoms consistent with trauma or PTSD in any treatment records. The examiner stated that although he reported being present during a large fire that resulted in many deaths and assisting in the recovery efforts, the Veteran was not reporting any pattern of re-experiencing, avoidance, numbing, or hyperarousal that met the diagnostic criteria for PTSD. Further, he had never been diagnosed with PTSD. Psychological testing results appeared invalid. The examiner commented that the Veteran scored a 74 out of a possible 88 on the Impact of Events Scale Revised (IES) with regard to the fire in Japan. He reported a 4 on almost all of these items and failed to discriminate adequately between symptoms on this measure. He also scored a 134 on the Mississippi Scale for Combat Related PTSD (MSC), which fell far above the cutoff that would be necessary for a diagnosis of PTSD, even in a Veteran exposed to frequent combat experiences. He reported symptoms in excess of what were reported during clinical interview, and symptoms were not consistent with functioning. The Veteran was diagnosed as having Bipolar Disorder with psychotic features, unrelated to military service. Although he described being present during a fire at a U.S. Naval base in Japan and assisting with firefighting and body recovery efforts, the examiner observed he did not report any pattern of symptoms indicative of PTSD. He did not seek or require any psychiatric treatment until 1977, which was 10 years after military discharge. He had been in psychiatric care since that time, but diagnoses included paranoid schizophrenia and Bipolar Disorder with psychotic features. He had never been diagnosed with PTSD by any provider, and his treatment notes did not have any indication of discussions about stressful events or memories from his military service. Therefore, his current psychiatric distress was unrelated to his military service. Subsequently, the Veteran and his wife were seen by a VA psychologist in August 2010, for "issues associated with possibly obtaining service-connected benefits." The Veteran stated that he started receiving intramuscular injections every two or three weeks, perhaps two months before his discharge from the Navy. The examiner noted these might have been haloperidol deaconate. Evidently, these treatments continued for some months following his discharge. That medication appeared to be associated with his diagnosis of Bipolar Disorder. For some period of time following discharge he did not receive any treatment or medication, but did end up being hospitalized for psychiatric reasons. The Veteran gave a history of significant drug and alcohol problem in the years following his discharge from the Navy. The Veteran also talked about some events associated with his service years that continue to affect him. In addition to assisting in removing bodies from a fire that occurred while he was in Tokyo [sic], the Veteran talked about aspects of the Vietnam war that continue to distress him. He talked about his involvement in communications, and how some aspects of this caused him to realize that information presented to the public about operations and also personnel were not accurate. He provided examples of these inaccuracies, and was tearful while so doing. He had symptoms of depression, sleep disruption with dreams of his military experience, recurrent intrusive memories, distress at exposure to cues some avoidance of stimuli, and some increased arousal. The diagnoses were Bipolar Disorder and rule out PTSD. With regard to the Veteran's questioning of the accuracy of the prior diagnosis, the psychologist explained that in general, disorders such as schizophrenia spectrum illnesses and Bipolar Disorder, though having some similarities with PTSD (for example could make people irritable), would be usually differentiated by clinicians. Further investigation regarding PTSD was to be planned with the PTSD team. Such psychiatric evaluation was conducted in October 2010. The Veteran presented to the evaluation describing current depressed mood, sleep disturbances, and nightmares of a fire in Japan. When asked to describe his current problems, the Veteran began by stating that he believed that he had PTSD, and not schizophrenia or Bipolar Disorder, as previously diagnosed. On the evaluation, the first symptom the Veteran reported was fear of fire. He was unable to estimate the last time he lit a match. His wife added that he will not attempt to re-light the pilot on their gas stove but instead will ask her to do it. She also stated that when she does light a match, the Veteran insists she run water over it to ensure it is fully extinguished before disposing of it. The Veteran began crying while speaking about his fear of fire and began to describe the fire in Japan in which he was involved during the Navy. The Veteran stated "putting out the fire was one thing; dragging bodies out was the other." He stated that in the previous 6 months he had begun doing research on the internet about that fire, and he was surprised to learn how many people had died. He stated that "officers were sending guys back into the building to get as much [classified military documents] out as possible." The Veteran stated that the men did not have proper masks to prevent smoke inhalation and passed out from the smoke, then drowned. He stated that the men's "bellies were swollen" from the water they had taken in while passed out inside the building. The Veteran reported that he sometimes had nightmares about the fire. He indicated that he awakened from those nightmares in a cold sweat. In addition to nightmares, the Veteran said that he had difficulty sleeping at night, often sleeping only a few hours at a time. He recalled that he burned a grilled cheese sandwich a few months earlier because he fell asleep. He stated that he became very upset when he woke up and smelled the smoke, but he was able to air out the house before his wife returned home from work. On mental status examination, the Veteran reported that his mood had been somewhat depressed and anxious. His facial affect was congruent with that report, and he became tearful during the interview. He spoke slowly and quietly at times. Otherwise, mental status examination was essentially normal. Psychometric testing, consisting of Clinical Interview Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Millon Clinical Multiaxial Inventory III (MCMI-III), was conducted. The MMPI-2 indicated a valid profile. His infrequency scale was slightly elevated, but still within the typical range observed in outpatients, thus not suggesting random responding or faking bad. Other validity scales were within the normal range. His clinical profile indicated an elevation on the hysteria scale. He also had an elevation on an index indicative of schizoid personality patterns. The results of the psychological testing were consistent with his verbal reports and history. He reported somatic symptoms including difficulty sleeping and daytime fatigue. He reported a history of panic attacks, as well as current examples of phobic avoidance pertaining to fire. Additionally, he had demonstrated a pattern of minimizing his social interactions by working the night shift and engaging in solitary activities away from his wife or other family members, which were consistent with his profile on the psychological testing. Reference was made to the Veteran's described patterns of avoidance and excessive fear pertaining to fire, and that this fear caused interference with cooking and potentially burning food. Specific phobia, situational type, was thereby given as a diagnosis. Additionally, he had long-standing patterns of preferring to avoid interacting with other people, even working nightshifts in order to do so, and maintaining few close relationships, which were consistent with schizoid personality traits on Axis II. The diagnostic impressions were bipolar I disorder, most recent episode depressed; specific phobia, situational type (fire); and schizoid personality traits. PTSD was found not to be present. Although the Veteran complained of depressed mood and nightmares, the examiner concluded that the diagnosis of Bipolar Disorder with psychotic features given to him in the late 1970's seemed consistent with his reported symptoms. The Veteran has apparently not had a manic episode in many years, but the episodes reported in the 70's included auditory hallucinations, homicidal ideation, and racing thoughts; additionally, they were severe enough that the Veteran was hospitalized. Although he had some symptoms of anxiety, as supported by both his verbal report and his psychological testing, he did not meet the criteria for PTSD. As noted above, a JMR indicated that the November 2009 VA examination was not adequate. Specifically, it was noted that the examiner did not discuss the events in service the Veteran reported, such as excessive alcohol consumption, engaging in fights, falling asleep while on duty, and receiving reprimands for unauthorized absences and sleeping on duty. The JMR found that such events could indicate the onset of a psychological disorder while in service, yet the examiner did not opine as to whether those symptoms indicated an in-service onset of a psychiatric disorder. Subsequent to the Board's remand, an addendum opinion was obtained in September 2016. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner indicated that contrary to what was stated in the JMR, the in-service incidents were noted previously during the November 2009 VA examination conducted by the same examiner and were identified as drinking alcohol heavily while stationed in Japan, engaging in some fights, falling asleep on the job, and unauthorized absence for two days. The examiner noted that the Veteran was honorably discharged in September 1966, so there was no continuing or ongoing incidents or difficulty in service that resulted in anything other than an honorable discharge. She also noted that there was no record of any psychiatric symptoms, diagnosis or treatment within one year of discharge. She stated that psychiatric symptoms were not first diagnosed or treated until the late 1970s, according to the records. The examiner concluded that these were not psychiatric symptoms and it was less likely that the incidents of alcohol dependence and falling asleep on watch were related to the current diagnosis of Bipolar Disorder. The examiner further added that the mental disorder did not emerge until many years after military discharge and that the Veteran's reports of in-service incidents such as alcohol abuse and behavioral issues occurred prior to his claimed stressor event of being exposed to a fire in 1965 and, therefore, could not be a result or consequence of the stressor event. In February 2017, the Veteran submitted a "PTSD DBQ" completed by his treating psychiatrist at the VAMC Pittsburgh. The psychiatrist rendered diagnoses of Bipolar Disorder, unspecified, and PTSD, unspecified. It was noted that it was possible to distinguish the symptoms of each psychiatric disorder. Bipolar Disorder was noted to be manifested by episodes of mania and depression not closely related to any claimed triggers, while PTSD symptoms were noted to include hypervigilance, nightmares, "and other symptoms associated triggers related to trauma." The psychiatrist opined that alcohol abuse during the military was used to self-medicate intrusive thoughts related to traumatic experiences. It was noted that the in-service stressors included an incident of a fire with casualties and friendly fire that occurred nearby and was the source of intrusive ruminations and nightmares. In May 2017, the Veteran submitted a private psychological assessment authored by a licensed psychologist/jury consultant. The psychologist indicated that the Veteran experiences symptoms of anxiety and nervousness when exposed to stimuli that remind him of his traumatic incident, flashbacks, avoidance tendencies, intrusive memories, anger towards himself or others, depression, difficulty with concentration, difficulty adapting to stressful situations, guilty feelings pertaining to his traumatic incident, exaggerated startle response, irritability, persistent withdrawal, self-isolation, feeling that he is re-living the traumatic event, an inability to establish and maintain effective relationships, and an inability to recall important aspects of the trauma. The psychologist concluded that it was at least as likely as not that the Veteran meets the DSM-IV and DSM-V criteria for PTSD. Furthermore, the psychologist disagreed with prior diagnoses of Bipolar Disorder and noted that there was no clear indication of such diagnosis, since the Veteran "does not currently experience the symptoms and does not take medication for Bipolar Disorder." He also found that the PTSD symptoms were clearly established with trigger stressors while the alleged bipolar symptoms were vague. The psychologist opined that the Veteran's PTSD developed as a result of an in-service stressor, specifically the fire on the base while stationed in Japan. The psychologist also opined that the Veteran met the criteria for depressive disorder, agoraphobia without panic disorder, and general anxiety disorder, and that it was more likely than not that these disorders stemmed from his military experiences. He explained that the depressive disorder, agoraphobia without panic disorder, and general anxiety disorder overlapped with the PTSD in such a way that the social and occupational impact of each could not be separated. Consequently, in June 2017, the RO obtained an addendum opinion from a Board of three licensed VA psychologists ("Board of 3" or psychologists herein) requesting an opinion as to whether or not the Veteran has a diagnosis of PTSD. The opinion noted that each psychologist of "The Board of 3" reviewed the Veteran's entire file independently in preparation of rendering the opinion, including the newly received medical evidence by the private psychologist. All three psychologists were in agreement that the Veteran does not meet the criteria for a diagnosis of PTSD and that his Bipolar Disorder diagnosis was not related to service. The psychologists noted that the Veteran first sought mental health treatment in the community in 1977 because he was hearing voices. The Veteran was hospitalized involuntarily in March 1978 for bizarre behavior, speech difficulty, extreme assaultiveness, auditory hallucinations, and delusional behavior. He was diagnosed with paranoid schizophrenia. The Veteran was hospitalized again in 1980 and has been followed by outpatient psychiatry at the VAMC Pittsburgh since 1992. He was consistently treated with mood stabilizers, including Lithium, Depakote, and Abilify, which are prescribed for bipolar/mood disorders, and antipsychotics including Haldol, which are prescribed for psychotic disorders. It was further noted that the records show that his Bipolar Disorder had been stable for many years with no complaints of PTSD symptoms until 2010. In 2010, psychiatry records show that the Veteran had been advised by an attorney to document symptoms of PTSD following the RO's denial of service connection for PTSD. After this notation, some providers specifically noted "r/o" (rule-out) for PTSD, indicating that PTSD had been considered, but that there was not sufficient evidence to warrant making the diagnosis. With regards to the VA psychiatrist diagnosis of PTSD "secondary to military combat," rendered in October 2016, the "Board of 3" indicated that it was based on reports of exposure to combat, despite the Veteran not having any combat experience and clearly denying exposure to combat at his 2009 VA examination, and the psychiatrist did not specify what stressors such diagnosis was based on. The "Board of 3" acknowledged the Veteran's reports of excessive drinking during his military service and the fire incident while stationed in Japan. With regards to the fire incident, it was noted that the Veteran previously reported feeling most upset about that fact that officers "didn't care about the people at all" by sending them in to try to save written records in the burning buildings. It was further noted that based on this report, the November 2009 examiner diagnosed the Veteran with Bipolar Disorder and indicated that he did not meet the DSM-IV criteria for PTSD, since he did not report PTSD symptoms such as re-experiencing, avoidance, numbing, or hyperarousal. In regards to the February 2017 "PTSD DBQ," the psychologists indicated that the "DBQ" was authored at the request of the Veteran for the purposes of his claim for service connection. The psychologists indicated that since the 1990s, the Veteran's previous psychiatry providers had indicated diagnoses of a mood disorder such as Bipolar Disorder or schizoaffective disorder and had not diagnosed PTSD, while the Veteran's current psychiatrist indicated a diagnosis of PTSD beginning in October 2016, in addition to Bipolar Disorder. While the "PTSD DBQ" indicated DSM-V diagnoses of Bipolar Disorder, unspecified, and PTSD, unspecified, the psychologists noted that the report does not provide enough information to establish a diagnosis of PTSD. Specifically, it was noted that the psychiatrist diagnosed the Veteran with PTSD related to combat based on his self-reports, but he had not had access to the Veteran's military records which show no combat experience. Moreover, no specific stressor was noted. In regards to the May 2017 private psychological evaluation, the "Board of 3" first noted that it was rendered by an out of state licensed psychologist and jury consultant, who indicated that the Veteran was referred for an assessment by his attorney for the specific purpose of supporting his claim for service connection for PTSD and Bipolar Disorder. It was further noted that the interview was conducted over the telephone. The psychologist offered diagnoses of PTSD, major depressive disorder, agoraphobia without panic disorder, and generalized anxiety disorder under both DSM-IV and DSM-V. The "Board of 3" noted that this evaluation was not credible for several reasons. First, it was noted that the examination was conducted of the telephone, which the "Board of 3" indicated was not standard practice for conducting compensation and pension initial examinations for diagnostic purposes, since a telephone based interview does not allow the examiner to make behavioral observations that serve as valuable clinical information. The psychologists noted that a great deal of information can be missed by not being able to observe the Veteran's affect, presentation, and response style over the course of the interview. Second, the "Board of 3" indicated that while the provider stated that psychological tests were administered, none of the tests were known reliable and valid PTSD assessment measures. It was also not clear how the tests were administered, since the evaluation did not take place in person. Third, the "Board of 3" stated that the diagnoses rendered by the provider were problematic for a few reasons. DSM diagnostic criteria were not applied correctly, because many of the same symptoms were used to make four different diagnoses that have considerable overlap. The "Board of 3" noted regarding the overlap between major depressive disorder and PTSD, the DSM-5 states, "Major depression may or may not be preceded by a traumatic event and should be diagnosed if other PTSD symptoms are absent." In other words, a clinician should only diagnose major depressive disorder if the symptoms of depression were not considered as part of the PTSD syndrome, but if depression is counted as a PTSD symptom, then major depressive disorder should not be diagnosed without having a sound rationale for doing so. Regarding the overlap between PTSD and anxiety disorder, the DSM-V states that if the anxiety symptoms are related to a specific traumatic event, then PTSD is diagnosed, but if not, then anxiety disorder is diagnosed. The "Board of 3" noted that the private opinion did not explain or provide a rationale for utilizing four different diagnoses to account for the Veteran's symptoms as well as failed to discuss the etiology of each condition. The "Board of 3" also indicated that the private opinion "chose to disregard" 40 years of the Veteran's treatment records and diagnostic conclusions, which have indicated the existence of Bipolar Disorder/schizoaffective process. The psychologists specifically indicated that the statement "the veteran does not currently experience the symptoms and does not take medication for Bipolar Disorder," was inaccurate, as the Veteran's records clearly indicate that he has been taking Haldol, prescribed by his VA psychiatrists for diagnoses of either bipolar or schizoaffective disorder since March 2011. It was noted that prior to that time, he was prescribed various mood stabilizers as noted above, and VA pharmacy records show that the Veteran was still taking Haldol at the time the private opinion phone interview was conducted. The "Board of 3" further noted that the private opinion failed to recognize that the likely reason the Veteran did not exhibit active manic or psychotic symptoms was because "he has been therapeutically maintained on an antipsychotic" for many years. Additionally, the "Board of 3" noted that residual bipolar symptoms were misattributed to the four diagnoses that the private psychologist rendered, and in its failure to diagnose either Bipolar Disorder or schizoaffective disorder, the private opinion, based on a one-time telephone interview, contradicted the Veteran's treatment providers who have known the Veteran over many years through repeated, in-person interactions. The psychologists also noted the private opinion's failure to account for a large portion of the Veteran's historical symptom presentation, despite the fact that four different diagnoses were offered. Regarding the diagnostic criteria for PTSD, the "Board of 3" noted that the records show that the Veteran has consistently reported the 1965 fire incident in Japan. The psychologists indicated that this event would meet criterion A toward a PTSD diagnosis. However, it was further noted that in order to meet diagnostic criteria for PTSD according to DSM-V, the Veteran would also need to report at least six clinically significant symptoms that fall within four different symptom clusters. The Veteran, when he was initially evaluated in 2009 under DSM-IV, did not meet the other symptom criteria for PTSD, and was therefore not diagnosed with the disorder. The "Board of 3" noted that since the Veteran's current psychiatrist has offered a diagnosis of PTSD, the Veteran's most recent psychiatry progress notes were carefully evaluated for mention of PTSD symptoms. The "Board of 3" indicated that the Veteran's Bipolar Disorder diagnosis was well established for many years. After symptoms of that disorder were factored out (because the same symptoms should not be used to account for two separate diagnoses), no additional reported symptoms were sufficient for a diagnosis of PTSD. Specifically, he did not appear to meet symptom criteria C or D. Also, there was no clear link between a specific stressor and the nature of symptoms experienced, as required for a diagnosis of PTSD. The "Board of 3" noted that for example, if the Veteran's stressor was to be considered the fire in Japan, it was unclear why irritability about his mistreatment after Vietnam was considered a PTSD symptom, as this had nothing to do with witnessing the fire, but rather, irritability was a known symptom of mood disorders such as Bipolar Disorder. The "Board of 3" concluded that the Veteran does not meet the DSM-IV or DSM-V diagnostic criteria for PTSD, but rather only meets the DSM-V criteria for Bipolar I Disorder, with Psychotic Features. They determined that symptoms of this disorder first manifested in 1977, nine years after discharge from active duty. The "Board of 3" opined that the fact that symptoms of Bipolar Disorder were not manifested in service or shortly after service leads to the conclusion that such disorder was less likely than not caused or aggravated by the Veteran's reported active duty stressors. Analysis 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 claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran asserts that he has an acquired psychiatric disorder, specifically PTSD, that is related to his service as a firefighter during a September 1965 incident of a fire on his base in Japan, which resulted in casualties that required him to recover bodies. Alternatively, the Veteran noted an incident of friendly fire that occurred close to where he was and was the source of his nightmares and intrusive ruminations. See e.g., August 2009 Statement in Support of Claim. However, this incident was not found by any mental health professional throughout the years to have been related to any psychiatric disorder. The JSRRC coordinator, in November 2009, determined that the stressor of the fire incident occurred. The report noted that the Veteran claimed that he helped with the firefighting, body recovery, and clean-up of a fire at Kamiseya. Review of that station's history showed that at the time of the fire, the station only had 300 personnel and 100 of them were in the building at the time of the fire, which resulted in the loss of 12 personnel who were killed. It took 12 fire departments as well as the US Naval personnel to extinguish the fire. The Coordinator noted that review of the Veteran's personnel file showed he was stationed at this location at the time of the fire. Due to the size of the fire and number of personnel at the base and assisting in the firefighting, it was their determination that the occurrence of the stressor was conceded despite their inability to identify the specific whereabouts of the Veteran at the time. After a careful review of the record, the Board finds that the preponderance of the evidence is against the claim for entitlement to service connection for an acquired psychiatric disorder, to include PTSD and Bipolar Disorder. The threshold element in any service connection claim is evidence of a current disability. The record contains conflicting evidence as to the existence of a current diagnosis of PTSD as well as to whether a currently diagnosed Bipolar Disorder is related to the Veteran's service. Initially, the Board acknowledges that the Veteran is competent to describe events that he witnessed or experienced during military service and that he is competent to describe psychiatric symptoms that he may experience. See Barr v. Nicholson, 21 Vet. App. 303 (2007). However, a diagnosis of a psychiatric disorder requires not just observation of certain symptoms, but also specialized training to diagnose psychiatric disorders. Additionally, a probative medical opinion on the etiology or underlying causes of any other psychiatric condition likewise requires the specialized training of a medical professional. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). As noted above, medical evidence in support of the claim is private psychologist assessment authored by Dr. M. in June 2017 showing diagnoses of PTSD, major depressive disorder, agoraphobia without panic disorder, and generalized anxiety disorder, an October 2016 diagnosis of PTSD secondary to combat experiences, and February 2017 "PTSD DBQ" showing a diagnosis of PTSD, unspecified, and Bipolar Disorder, unspecified. While the "PTSD DBQ" failed to provide a rationale for the diagnosis of PTSD and opinion relating it to service, the private psychologist provided such rationale. To the contrary, however, evidence unfavorable to the claim includes a November 2009 VA examination report and a September 2016 addendum opinion, which indicated that the Veteran does not meet the criteria for a diagnosis of PTSD and that his Bipolar Disorder was not related to service. As previously indicated, the November 2009 examination was found to be inadequate. With regards to the addendum opinion, the Board finds that the examiner noted the in-service reports of alcohol abuse and behavioral issues, and explained that the claimed stressor for PTSD was with regards to the fire incident, which occurred later during service, and as such could not be the early onset of PTSD. Nevertheless, the examiner did not provide an adequate rationale as to whether these symptoms could have been the early onset of the diagnosed Bipolar Disorder. However, additional evidence unfavorable to the claim includes the "Board of 3" June 2017 opinion, which concluded that the Veteran does not meet the criteria for a diagnosis of PTSD and that his Bipolar Disorder was not related to service, and explained why the conflicting evidence is not reliable. When reviewing such 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). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Having reviewed all of the favorable and unfavorable opinions above, the Board assigns more probative weight to the June 2017 "Board of 3" opinion that the Veteran does not currently meet the diagnostic criteria for a diagnosis of PTSD and that his current diagnosis of Bipolar Disorder is not related to service. This opinion is highly probative, as it represents the informed conclusions of three different licensed psychologists supported by a thorough explanation based on the clinical findings and the symptomatology reflected in the medical and lay evidence of record. See June 2017 Board of 3 opinion (reflecting that the Board consisted of three licensed psychologists who each reviewed the record independently prior to rendering a unanimous opinion). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that the probative value of a medical opinion comes from its reasoning); Prejean, 13 Vet. App. at 448. Not only is the June 2017 opinion of the "Board of 3" highly probative, it is the most comprehensive opinion of record which necessarily outweighs the less probative, prior impressions of PTSD. The June 2017 opinion specifically refuted the assessments of other mental health providers, including the May 2017 private psychologist's opinion, and provided a persuasive explanation as to why this opinion is not adequate. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a Veteran's medical records). Indeed, the "Board of 3" had an opportunity to review the prior impressions of acquired psychiatric disorders rendered by the VA mental health professionals and May 2017 private psychologist. Notably, the "Board of 3" June 2017 opinion determined that Dr. M.'s May 2017 opinion is based on a phone interview only with reliance on inaccurate factual information, such as the Veteran not taking any medication for Bipolar Disorder. Furthermore, the "Board of 3" explained why the diagnoses rendered by the private psychologist, to include PTSD, were not in compliance with neither DSM-IV nor DSM-V. Accordingly, although mental health care professionals are presumed to know and take into account the DSM criteria in diagnosing PTSD, given the failure of those who provided diagnoses of PTSD to identify the symptoms which meet the criteria for a diagnosis, coupled with the lack of a comprehensive review of the Veteran's claims file and misstated information from the records, the Board must assign the prior impressions of PTSD, little probative weight. See Cohen, 10 Vet. App. at 139-42. See also Guerrieri, 4 Vet. App. at 471-73; Prejean, 13 Vet. App. at 448. The Board observes that the "Board of 3" persuasively confirmed a diagnosis of Bipolar Disorder, but determined that the bipolar disorder was not related to service. As discussed above, the Board places high probative weight on the June 2017 medical opinion. Additionally, while the Veteran's service treatment records were not available, the Board finds that the fact that such disorder showed no symptoms until many years after separation is enough to suggest that it did not have its onset during service, specifically, because the Veteran's currently diagnosed Bipolar Disorder is not etiologically related to the his claimed in-service stressors. Furthermore, the "Board of 3" noted that the alcohol abuse and behavioral issues in-service were not an early manifestation of his later diagnosed Bipolar Disorder. Further, the Board recognizes the Veteran's medical records indicating a diagnosis of alcohol abuse. However, direct service connection for disability resulting from a claimant's own drug or alcohol abuse is precluded for all VA benefit claims filed after October 31, 1990. See VAOPGCPREC 7-99; VAOPGCPREC 2-98. Compensation cannot be awarded pursuant to 38 U.S.C. §§ 1110, 1131 and 38 U.S.C. § 105(a) either for primary alcohol abuse disabilities or for secondary disabilities that result from primary alcohol abuse. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Primary alcohol abuse disability means an alcohol abuse disability arising from voluntary and willful drinking to excess. Id. However, service connection may be granted for an alcohol or drug abuse disability as secondary to, or as a symptom of, a service-connected disability. See Allen, 237 F.3d 1368 at 1375. A veteran must adequately establish, through clear medical evidence that an alcohol or drug abuse disability is secondary to or caused by a primary service-connected disorder, and not due to willful wrongdoing. Id. at 1381. In this case, service connection for a substance abuse disorder may only be allowed where there is clear medical evidence that it is the direct result of a service-connected disorder, and such has not been shown in this case. Accordingly, the Board finds that the weight of the probative evidence indicates that the Veteran's symptoms do not meet the DSM criteria for a diagnosis of PTSD, and that his diagnosed Bipolar Disorder is not etiologically related to his service. The law limits entitlement for service-related diseases and injuries to cases where an underlying in-service incident has resulted in the claimed current disability. See 38 U.S.C. §§ 1110, 1131; see also Brammer v. Derwinski, 3 Vet. App. 223 (1992). In summary, there is no competent and probative evidence showing that the Veteran meets the diagnostic criteria for a current diagnosis of PTSD and his Bipolar Disorder has not been related to his service through competent and probative evidence. Therefore, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for an acquired psychiatric disorder is denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs