Citation Nr: 1755419 Decision Date: 12/01/17 Archive Date: 12/11/17 DOCKET NO. 08-08 582 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), dysthymic disorder, and adjustment disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Rothstein, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1972 to February 1975. This appeal to the Board of Veterans' Appeals (Board) arose from a December 2007 rating decision, in which the RO, inter alia, denied service connection for PTSD. In January 2008, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in March 2008, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) that some month. In April 2009 and March 2010, the Veteran testified during a hearing before a Decision Review Officer (DRO) at the RO. Transcripts of those hearings are of record. In August 2010, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge (VLJ) at the RO. A transcript of that hearing is also of record. In May 2009 and May 2010, the RO, inter alia, continued to deny the Veteran's claim for service connection for PTSD (as reflected in May 2009 and May 2010 supplemental SOCs (SSOCs)). In June 2011, the Board, inter alia, remanded the Veteran's claim for service connection for PTSD to the RO, via the Appeals Management Center (AMC), in Washington, D.C., for further action, to include additional development of the evidence. After taking further action, the AMC continued to deny the claim for service connection for PTSD (as reflected in a May 2012 SSOC), and returned the matter to the Board for further appellate consideration. In December 2013, the Board expanded the claim on appeal to include any acquired psychiatric disorder, consistent with Clemons v. Shinseki, 23 Vet. App. 1 (2009) (as reflected on the title page), and remanded the expanded claim to the AMC for further action, to include additional development of the evidence. After taking further action, the AMC denied the claim for service connection for an acquired psychiatric disorder (as reflected in a June 2014 SSOC), and returned the matter to the Board for further appellate consideration. In August 2014, the Board remanded the claim for service connection for an acquired psychiatric disorder to the agency of original jurisdiction (AOJ) for further action, to include additional development of the evidence. After taking further action, the AOJ continued to deny the claim (as reflected in a February 2015 SSOC), and returned the matter to the Board for further appellate consideration. In December 2015, the Board again remanded the claim for service connection for an acquired psychiatric disorder to the AOJ for further action, to include additional development of the evidence. After taking further action, the AOJ continued to deny the claim (as reflected in an October 2016 SSOC), and returned the matter to the Board for further appellate consideration. In February 2017, the Board again remanded the claim for service connection for an acquired psychiatric disorder to the AOJ for further action, to include additional development of the evidence. After taking further action, the AOJ continued to deny the claim (as reflected in a September 2017 SSOC), and retuned the matter to the Board for further appellate consideration. While the Veteran previously had a paper claims file, this appeal is now being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Virtual VA (Legacy Content Manager) claims processing systems. All records have been reviewed. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. Although VA has essentially conceded the occurrence of in-service stressors associated with fear of hostile military or terrorist activity, the weight of the competent, probative evidence indicates that the Veteran does not meet the diagnostic criteria for a current diagnosis of PTSD. 3. The weight of the competent, probative evidence indicates that no other diagnosed acquired psychiatric disorder, to specifically include dysthymic disorder and adjustment disorder, had its onset during service, or is otherwise medically related to service, to include any stressful experiences therein. CONCLUSION OF LAW The criteria for establishing service connection for an acquired psychiatric disorder, to include PTSD, dysthymic disorder, and adjustment disorder, are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, , 4.125 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2017). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet App. 112 (2004), and Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status; existence of a disability; a connection between the veteran's service and the disability; degree of disability; and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AO. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this case, a March 2007 pre-rating letter provided notice to the Veteran regarding the information and evidence needed to substantiate the claim for service connection herein decided, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. In addition, this letter provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates-in the event service connection was awarded-as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. As the December 2007 rating decision reflects the RO's initial adjudication of this claim for service connection after the issuance of the March 2007 letter, this letter meets the VCAA's content and timing of notice requirements. Also, consistent with applicable duty to assist provisions of the VCAA, the record reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant evidence pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of the Veteran's service treatment records, VA treatment records (to include Vet Center treatment records), Social Security Administration (SSA) disability records, and reports of VA examinations/opinions. Also of record and considered in connection with the claim are the transcripts of the April 2009 and March 2010 DRO hearings and the August 2010 Board hearing, the Veteran's service personnel records, and various written statements provided by the Veteran and on his behalf. The Board finds that no further action to develop the claim herein decided, prior to appellate consideration, is required. The Board points out that, most recently, the Veteran was provided the opportunity to orally set forth his contentions during the August 2010 Board hearing. During that hearing, the undersigned enumerated the issues then on appeal, to include the claim for service connection herein decided. Pertinent to this issue, testimony was elicited from the Veteran regarding his claimed PTSD stressors and psychiatric symptoms. Although the submission of specific evidence was not explicitly suggested, any omission in this regard was cured by the further development subsequently conducted pursuant to the Board's remands. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103(c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Notably, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), to include identification of any prejudice in the conduct of the hearing. As for the most recent February 2017 remand, the Board instructed the AOJ to obtain treatment records from the VA Greenville Vet Center, obtain outstanding VA treatment records, request any additional information from the Veteran regarding outstanding private (non-VA) records, and obtain an addendum VA medical opinion. In response, treatment records from the VA Greenville Vet Center were obtained, updated VA treatment records were obtained, and the AOJ sent a letter to the Veteran requesting information concerning outstanding private (non-VA) records. Also, an addendum VA medical opinion was obtained in August 2017. Accordingly, the Board finds that, with respect to the claim decided herein, the AOJ has substantially complied with the prior remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where Board's remand instructions were substantially complied with). In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim herein decided. As such, there is no prejudice to the Veteran in the Board proceeding to a decision on this claim, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in line of duty. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Generally, in order to establish service connection on a direct basis, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) an etiological relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its competency, credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Certain chronic diseases, such as psychoses, shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service (one year for psychoses), even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit has clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology (in lieu of a medical nexus opinion) apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, there are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM)); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125. The Board notes that the Fifth Edition of the DSM (DSM-5) recently replaced the Fourth Edition of the DSM (DSM-IV). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with the DSM-5. The provisions of the interim final rule only apply, however, to all applications for benefits that are received by VA or that are pending before the AOJ on or after August 4, 2014. Hence, for claims such as this one, in which an appeal was certified to the Board prior to August 4, 2014, diagnoses of PTSD must be rendered in accordance with the DSM-IV. The evidence needed to establish the occurrence of a claimed in-service stressor is typically dependent upon whether the Veteran engaged in combat with the enemy, as well as whether the claimed in-service stressor is related to such combat; or, if not, whether there is objective evidence to verify the occurrence of the claimed stressor. See 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 147 (1997); Moreau v. Brown, 9 Vet. App. 389, 395 (1996); see also 38 U.S.C. 1154(b) (2012). On July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the occurrence of in-service stressors involving "fear of hostile military or terrorist activity." See 75 Fed. Reg. 39843 (July 13, 2010), and 75 Fed. Reg. 41092 (July 15, 2010) (correcting the effective and applicability dates from July 12, 2010 to July 13, 2010). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-6 (1990). The Veteran contends that he has a current psychiatric disorder, claimed as PTSD, as a result of his active service. Specifically, he alleges that while he was stationed aboard the USS Dubuque, he was deployed to Vietnam as part of a mine-sweeping mission, civilian boats were detonated by the mines, he was called to general quarters during enemy air attacks, and a soldier fell off the ship during the operation. The Board notes that these alleged in-service events were established to have possibly occurred in a March 2014 memorandum from the United States Army & Joint Services Records Research Center (JSRRC) (as related to the Veteran's fear of hostile military or terrorist activity) and were conceded by the AOJ in the June 2014 SSOC. Turning to the relevant evidence of record, service treatment records are negative of any psychiatric complaints, findings, or diagnoses during service. In the February 1975 separation report of medical history, the Veteran denied having or ever having frequent trouble sleeping, depression or excessive worry, and nervous trouble of any sort. In the February 1975 separation examination report, the Veteran was clinically evaluated as psychiatrically normal. In April 2008, during a VA primary care visit, the Veteran underwent a VA PTSD screen, which was negative. In March 2008, the Veteran underwent a psychiatric evaluation in connection with an SSA disability application for claimed physical disabilities, in which the Veteran reported that he "has a lot on him" due to his treatment of colon cancer. The examining physician diagnosed the Veteran with depression. A June 2008 VA primary care treatment note noted that the Veteran had dysthymic disorder, specifically "[d]epression with anxiety since cancer diagnosis." The treatment note also noted that the Veteran had been diagnosed with colon cancer around September 2007. In April 2010, during a VA mental health intake assessment, the Veteran requested to be seen because he had PTSD. As such, in July 2010, he was scheduled for a VA mental health appointment. At that appointment, the Veteran's chief complaint was that he couldn't sleep, and that everything regarding war made him think of Vietnam. More specifically, he reported that he slept about four to five hours, was easily awakened, had nightmares two to three times per week, had flashbacks, noises startled him, was irritable when in a bad mood, and didn't talk to anyone. He also reported being on minesweeper duty and in combat in Vietnam. He also reported that he felt depressed; and with regard to this, the VA psychiatrist noted that he was diagnosed with colon cancer three years ago and underwent chemo and radiation therapy. The Veteran also reported significant financial stress and being at risk of losing his home. He also indicated that he had no psychiatric care in the past. The attending VA physician provided initial DSM-IV diagnoses of adjustment disorder with mixed anxiety/depression and of PTSD. The VA physician also noted the Veteran's current psychosocial stressors were financial and past combat experience. In July 2010, the Veteran also began therapy sessions at the VA Vet Center, which included discussion of the Veteran being very upset and grieving over the loss of his father. The same VA physician who diagnosed the Veteran with PTSD in July 2010 continued to note impressions of adjustment disorder and of PTSD in May 2011 and July 2013 VA mental health medication management notes. In July 2013, the physician noted that the Veteran's adjustment disorder was in the context of bereavement over multiple recent losses (e.g. father, son killed in robbery, wife died unexpectedly from breast cancer, and father-in-law). In April 2014, the Veteran underwent a VA contracted PTSD examination, in which he described military traumatic experiences, including witnessing civilian boats being detonated by mines, civilian boats being destroyed by helicopters, one military personnel death due to falling overboard, and several attacks on his ships which could have resulted in death of himself and fellow military personnel. He also described several post-military traumatic events, including a cancer diagnosis, the shooting death of his son, the shooting injury of his daughter, the death of his father and of his wife. He reported that the latter four events occurred within a six month period and followed his cancer diagnosis. Upon examination, the examiner diagnosed the Veteran with adjustment disorder with mixed anxiety and depressed mood. The examiner found that the Veteran did not have a diagnosis of PTSD that conformed to DSM-5 or DSM-IV criteria. In this regard, the examiner indicated that the Veteran did not meet the DSM-IV A1 criterion or the DSM-V D or E criteria. The examiner also explained that the Veteran reported that he experienced no mental health symptoms after discharge from military service and had no difficulty adjusting to civilian life; that he related his current mental health difficulties to the diagnosis of cancer and subsequent loss of employment; and that the subsequent loss of his son, father and wife, along with the wounding of his daughter by shooting further compromised his mental health. The examiner further explained that it was difficult to discern if the Veteran experienced true recurrent, intrusive, distressing recollections of traumatic events during his service. The examiner also opined that the Veteran's current psychiatric disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner likewise reasoned that the Veteran reported that he experienced no mental health symptoms after discharge from military service and had no difficulty adjusting to civilian life; that he related his current mental health difficulties to the diagnosis of cancer and subsequent loss of employment; and that the subsequent loss of his son, father and wife, along with the wounding of his daughter by shooting further compromised his mental health. In an October 2014 addendum medical opinion, the examiner who conducted the April 2014 VA contracted examination opined that "[t]he veteran is not suffering from a psychological disorder related to his service experience, but rather from events post-service (the diagnosis of cancer followed by several family member deaths), which resulted in diagnosable symptoms of both depression and anxiety." In September 2016, the Veteran was afforded a VA medical opinion, in which the providing VA psychologist opined that the Veteran had not met the full criteria for a PTSD diagnosis by DSM-IV or DSM-5 standards at any time following service. The VA psychologist also opined that the Veteran's symptoms of depression and anxiety (i.e., dysthymic disorder and/or adjustment disorder with mixed anxiety and depressed mood) were less likely than not due to his military service, but rather secondary to his cancer diagnosis. The VA psychologist explained that neither medical records nor psychosocial history in the April 2014 VA contracted examination supported a diagnosis of PTSD at any time post military service; that although the Veteran was diagnosed with PTSD in a July 2010 VA treatment note, the symptoms listed in the note did not meet the full criteria for a PTSD diagnosis (Criterion C under DSM-IV and Criteria C&D under DSM-5) and prior records did not suggest any PTSD symptoms were occurring prior to the note, including an April 2008 negative PTSD screen; and that medical records consistently supported symptoms of depression and anxiety that began with the Veteran's cancer diagnosis in 2007/2008 and then waxed and waned over the years according to life stressors (i.e., death of multiple family members, including his son and wife). In August 2017, the Veteran who provided the September 2016 VA medical opinion provided an addendum VA medical opinion, in which the VA psychologist opined that, after a review of the new evidence (specifically Greenville Vet Center treatment records), that her opinion remained the same as that provided in September 2016. She again opined that the Veteran had not met the full criteria for a PTSD diagnosis (by DSM-IV or DSM-5 standards) at any time following service, and that the Veteran's symptoms of depression and anxiety (i.e., dysthymic disorder and/or adjustment disorder with mixed anxiety and depressed mood) were less likely than not due to his military service, but rather were secondary to his cancer diagnosis. The VA psychologist provided the same explanation as above, but further explained that the Veteran's Vet Center treatment records did not indicate symptoms consistent with a PTSD diagnosis, nor did the records indicate focus on PTSD symptoms during treatment, and that rather, the records indicated focus on managing symptoms of depression around loss of family members, financial stress, holiday planning, and conflict with his son. Considering the evidence in light of the governing legal authority, the Board concludes that the preponderance of the evidence weighs against a finding that the Veteran has, or has had met the diagnostic criteria for a PTSD diagnosis, at any time during the pendency of his claim, or that his dysthymic disorder or adjustment disorder is etiologically related to service. Regarding PTSD, the Board finds that the evidence of record does not persuasively establish that the Veteran has met the DSM-IV diagnostic criteria for a PTSD diagnosis at any time pertinent to this appeal. Rather, the weight of the competent, probative evidence indicates that the Veteran does not meet such diagnostic criteria. Notably, while the Veteran was diagnosed with PTSD under the DSM-IV in a July 2010 VA treatment note, and such diagnosis was again noted in May 2011 and July 2013 VA medication management notes, that VA physician who provided such diagnosis did not clearly identify and/or distinguish the Veteran's PTSD symptoms, establish if the full diagnostic criteria for a PTSD diagnosis were met, or offer a rationale as to why PTSD was diagnosed. Therefore the diagnosis provided by that VA physician is of limited probative value on the issue of current disability. Here, the Board finds persuasive on the question of whether the Veteran has met the diagnostic criteria for a PTSD diagnosis the September 2016 VA medical opinion and the August 2017 VA addendum medical opinion, which explicitly found that the Veteran did not meet the diagnostic criteria for a PTSD diagnosis under the DSM-IV at any time following service. The Board accords great probative weight to these opinions, as such was predicated on an in-depth review of the record. Moreover, the examiner clearly considered all of the pertinent evidence of record, to particularly include the July 2010 VA treatment note, and provided a complete rationale, relying on and citing to the records reviewed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("the medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Thus, because the weight of the evidence shows that the Veteran does not meet the diagnostic criteria for PTSD under the DSM-IV at any point pertinent to this appeal, he fails to meet the first requirement of his claim for service connection for PTSD. As a fundamental requirement for establishing service connection is not met, the Veteran cannot establish service connection for PTSD; hence, the remaining criteria under 38 C.F.R. § 3.304(f)-whether there is credible evidence that an in-service stressor occurred, and whether there is a nexus between the in-service stressor and diagnosed PTSD-need not be addressed. Regarding acquired psychiatric disorders other than PTSD of record, while the evidence of record shows that the Veteran has been diagnosed with dysthymic disorder and adjustment disorder, and that the AOJ has conceded that the Veteran's described alleged in-service events occurred (i.e., being deployed to Vietnam as part of a mine-sweeping mission, witnessing civilian boats being detonated by mines, being called to general quarters during enemy air attacks, and witnessing a soldier falling off the ship during the operation), the evidence fails to establish by competent and probative evidence that any such disability is related to service. As indicated, there is nothing in the Veteran's service treatment records, to include his separation report of medical history and examination report, to support a finding of a psychiatric disorder in service. In addition, the first clinical evidence of a diagnosis of an acquired psychiatric disorder was in March 2008, nearly 33 years after the Veteran was discharged from service. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Moreover, the Board notes that dysthymic disorder and adjustment disorder are not psychoses, as defined in the regulation. In this regard, according to 38 C.F.R. § 3.384, the term "psychosis" includes the following: brief psychotic disorder; delusional disorder; psychotic disorder due to another medical condition; psychotic disorder, not otherwise specified (NOS); schizoaffective disorder; schizophrenia; schizophreniform disorder; shared psychotic disorder; and substance-induced psychotic disorder. Hence, service connection based on presumed in-service incurrence of a chronic disability and continuity of symptoms pursuant to the provisions of 38 C.F.R. §§ 3.303(b) and 3.307 is not for application. Furthermore, the only competent, probative opinions to address the medical relationship, if any, between the adjustment disorder and dysthymic disorder diagnosed many years post-service and the Veteran's service weighs against the claim. The medical professionals who provided the April 2014, September 2016, and August 2017 VA opinions/addendum opinion explicitly rendered conclusions that weigh against a finding of service connection for dysthymic disorder or adjustment disorder. Such opinions clearly were based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale. As such, the Board accepts these opinions as probative of the medical nexus question. See Nieves, supra; Stefl, supra. Significantly, there is no contrary medical evidence or opinion of record-i.e., one that, in fact, establishes a medical nexus between current dysthymic disorder and/or adjustment disorder and service-and the Veteran has not presented or identified any such existing evidence or opinion. In addition to the evidence discussed above, in deciding his claim, the Board has considered the Veteran's own assertions that he has a psychiatric disorder, to include PTSD, that is related to service. However, such assertions provide no persuasive support for the claim. The matters here at issue are ones within the province of trained medical-specifically, mental health-professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Although lay persons are competent to attest to matters observed or otherwise within their personal knowledge, and to provide opinions on some related medical matters provide opinions on some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), the pertinent questions at issue here-whether the Veteran meets the diagnostic criteria for PTSD under the DSM-IV, and whether the Veteran's adjustment disorder and/or dysthymic disorder is etiologically related to service-are complex medical matters that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377, n. 4 (providing that lay persons are not competent to diagnose cancer). As the Veteran is not shown to be other than a layperson without appropriate training and expertise, he is not competent to render a probative (i.e., persuasive) opinion on the complex medical matters upon which this claim turns. Id. As, in connection with this claim, such lay assertions have no probative value, the Veteran can neither support his claim, nor counter the competent, probative opinions of record, on the basis of his own lay assertions, alone. For all the foregoing reasons, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD, dysthymic disorder, and adjustment disorder, must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. (CONTINUED ON NEXT PAGE) ORDER Service connection for an acquired psychiatric disorder, to include PTSD, dysthymic disorder, and adjustment disorder, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs