Citation Nr: 1756628 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 10-00 186 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and a bipolar disorder. REPRESENTATION Appellant represented by: National Association for Black Veterans, Inc. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Kipper, Associate Counsel INTRODUCTION The appellant served in the Army Reserves with verified periods of active duty for training (ACDUTRA) from June 23 to November 9, 1993, from August 16 to August 18, 1996, and from August 23 to August 28, 1996. This matter comes before the Board of Veterans' Appeals (Board) from a January 2009 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The appellant testified before the undersigned Veterans Law Judge at an April 2016 videoconference hearing, a transcript of which has been associated with the claims file. The case was previously before the Board in June 2016 and March 2017, at which time it was remanded for further development. FINDING OF FACT An acquired psychiatric disorder, to include schizophrenia and a bipolar disorder, was not incurred in, otherwise caused by, or aggravated by a period of ACDUTRA. CONCLUSION OF LAW The criteria for establishing service connection for an acquired psychiatric disorder have not been met. 38 U.S.C.A. §§ 101, 1101, 1131, 1113, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In the present case, VA's duty to notify was satisfied by way of an October 2008 letter to the appellant. VA also has a duty to assist the appellant in the development of the claim. This duty includes assisting the appellant in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. The appellant has not identified any outstanding evidence, to include any other medical records, which could be obtained to substantiate her appeal. Additionally, the Board finds that there has been substantial compliance with its previous remand directives, to include obtaining outstanding records, verifying the appellant's periods of service, providing the appellant with VA examinations, and obtaining etiology opinions. In light of the foregoing, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that all necessary development has been accomplished. Therefore, appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection The appellant seeks entitlement to service connection for an acquired psychiatric disorder, which she contends had its onset during her first period of ACDUTRA or was aggravated by her second period of ACDUTRA. A. 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 the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2017). The term active military service includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101 (24). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. When a claim for service connection is based on a period of ACDUTRA, there must be some evidence that the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). In the absence of such evidence, the period of ACDUTRA would not qualify as "active military, naval, or air service," and the appellant would not qualify as a "veteran" by virtue of ACDUTRA service alone. Id. See also 38 U.S.C.A. § 101(2), (24); 38 C.F.R. §§ 3.1(d), 3.6(c). Currently, service connection is not in effect for any disabilities. Thus, the appellant has not achieved "veteran" status. 38 U.S.C.A. § 101 (2), (24)(A)-(B); 38 C.F.R. §§ 3.1 (d); 3.6(a). As such, the presumption provisions of 38 C.F.R. §§ 3.307 and 3.309, as well as the presumptions of soundness and aggravation, are inapplicable. Hill v. McDonald, 28 Vet. App. 243 (2016); Smith v. Shinseki, 24 Vet. App. 40 (2010); Donnellan v. Shinseki, 24 Vet. App. 167 (2010). Instead, the burden is on the claimant to establish that she was disabled from a disease or injury incurred or aggravated in the line of duty during ACDUTRA, and to establish a causal relationship between the worsening of a preexisting condition and his ACDUTRA. Donnellan, 24 Vet. App. at 173-174. There is no shifting burden as there is when the presumptions of soundness and aggravation apply. Id. Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). In deciding the appellant's claim, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant 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.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the appellant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time which supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons and bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). B. Factual Background The appellant contends that symptoms of her acquired psychiatric disorder, variously diagnosed as schizophrenia and bipolar disorder, first manifested during her initial period of ACDUTRA from June to November 1993, even though it was not diagnosed until February 1996. Alternatively, the appellant contends that her acquired psychiatric disorder was aggravated by her second period of ACDUTRA in August 1996. In a June 2009 letter the appellant stated that before enlisting in the service she had never experienced any signs of mental illness. Once in the military, serving as a medic, she reported experiencing insomnia, paranoia, delusions, racing thoughts, and restlessness. Similarly, at the April 2016 videoconference the appellant testified that during her ACDUTRA in 1993 she had been highly competitive and that the concentration required for this was part of her bipolar disorder. She also testified that during this period of ACDUTRA, she had a lot of energy, but got very little sleep. Service treatment records from the appellant's first period of ACDUTRA show that she was seen for a skin rash in August 1993. There were no complaints or treatment related to an acquired psychiatric disorder. A November 1993 service record shows that the appellant was awarded a certificate of achievement for exemplary performance as Soldier of the Cycle. An April 1995 service record shows that the appellant was awarded the Army Achievement Medal for her work in the personnel section of her Reserve unit. Records of the appellant's first psychiatric hospitalization, at Mary Greely Medical Center in February 1996, show that she was admitted while in the midst of a psychotic episode. The appellant's friends brought her to the emergency room due to concern about changes in her behavior in the past two to three months. She was described as psychotic and visibly agitated. During admission, the treating clinician noted that as far as could be determined, the appellant "has had the onset these symptoms in the last two to three months." The appellant reported that she was a straight A student and that she was in the Reserves. She also reported that her father remarried in the past year, which was "somewhat stressful for her." She was hospitalized for 11 days, and at discharge, she was diagnosed with psychosis and rule-out bipolar disorder. An April 1996 private treatment record shows that the Veteran had "done well with no re-emergence of psychosis," and she was diagnosed with bipolar disorder, manic episode, in partial remission. An August 29, 1996 treatment record reflects that the appellant's father called her psychiatrist to report that the appellant had just been released from military training and needed to be seen. The Veteran reported that in the past several days, she started to have racing thoughts, and that her commander sent her back early from military training because "they felt that she just wasn't functioning well." The treating clinician indicated that her lithium levels while at training was "reportedly subtherapeutic" and that it was "subtherapeutic before she went on maneuvers and has been that way for a while." A September 1996 service school academic evaluation report shows that the Veteran attended a primary leadership development course from August 24, 1996, to August 28, 1996, and that she was released from the course early "for medical reasons." Records of the appellant's second period of psychiatric hospitalization, at Mary Greely Medical Center in September 1996, show that at admission the appellant was experiencing auditory hallucinations. Her father indicated that he was concerned that her military service might be too much for her to handle and "may be a precipitant to her relapse." He also indicated that the appellant had been sent home early from military training camp because she was not coping well. A February 1997 letter from J.T., M.D., stated that he had treated the appellant for a mood disorder, i.e., a bipolar disorder with psychotic features since April 1996. She had been hospitalized twice, most recently in September 1996. A June 1997 Reserves examination report indicated that the appellant took medications for a bipolar disorder and was being treated by a private physician. In an adjunct medical history questionnaire the appellant reported having or having had depression or excessive worrying. It was noted that she had a bipolar disorder for which she had been hospitalized in February and September 1996. The appellant was given Physical Profiles in July 1997 and July 1998 due to her bipolar disorder. During an August 1997 VA psychiatric examination the appellant reported that she was a junior at Iowa State University and a reservist. She reported that she had no problems up to and during high school, following which she became a reservist. She indicated that she served for five months of duty starting in June 1993 and had done well. The examiner indicated that, "[i]n retrospect, she does feel that she experienced some hypersexuality during her AIT experience in late August, September, and October [of 1993] which may represent some subtle symptoms of her bipolar disease." It was noted that the appellant had completed her training in November 1993 and entered Iowa State University in the spring semester of 1994. She had continued as a full-time student but missed the spring and fall semesters of 1996 due to psychiatric illness. It was also reported that "[t]he patient reports the onset of some depressive symptomatology during high school. She is unclear as to when it initially occurred. She thought it was her senior year." She recalled that her mother expressed some concern to her about her experiencing some depression. The symptoms tended to be seasonal in variation and appeared to cluster in the spring. She sought psychotherapy at Iowa State starting in the spring of 1994 and had continued it. The first major episode of illness occurred in late 1995 or early 1996 when she was hospitalized at Mary Greeley, having presented with paranoia and religious preoccupation. After discharge from that hospitalization she had been continued on Lithium but had another episode of delusional ideation in September 1996, the onset of which was while she was in reserve training at Ft. Chaffee. After only three or four days in the training setting, she was sent home to be evaluated and within two days was hospitalized again at Mary Greely for delusions. The examiner diagnosed bipolar affective disorder with a history of psychotic manic episodes. A May 1998 military record relative to the appellant's drill status noted that a physician's letter of April 1998 had excused the appellant from all reserve duties and that this letter would prevent her from attending annual training in June 1998. An August 1998 service treatment record reflects that the appellant was under treatment for bipolar disorder and that she was "fairly well controlled and functioning OK with her daily tasks." The appellant was honorably discharged from the Army Reserves in October 2000. A report of a VA psychiatric examination in November 2008 noted that it was very difficult to obtain a sequential timeline of the appellant's experiences. She had enlisted in the reserves in August 1992 and had been "let go" in January 2000. She had ACDUTRA from June to November 1993. She had training for about 2 weeks in 1996, at which time she felt that she was being harassed and began having paranoid thoughts, and she went to her supervisor. At the time of the current examination she brought a notebook and began explaining all the "episodes" she had ever had. She stated that her first "episodes" were in February 1996 when she had become very paranoid and a friend had then taken her to a hospital where she was hospitalized for about 3 weeks. Since then, she had had multiple psychotic episodes. After a mental status examination the diagnosis was schizophrenia. The examiner commented that the appellant reported that her first "episode" had been in 1996 during a training exercise but that her "active duty service" was listed as being from June to November 1993 and "hence, it appears as if the [appellant] was not active in the military and her active service did not permanently aggravate the claimed [psychiatric] condition." The appellant was afforded a VA examination in August 2016. The appellant reported that her mother took her to speak to a pastor at the church in 1989 for depression. After examining the Veteran and reviewing the claims file, the examiner opined that the appellant's psychiatric disability is less likely than not related to her first period of ACDUTRA. The examiner's rationale was that because the appellant experienced depression prior to enlistment, "the progression of bipolar began prior to her enlistment; prior to her period of ACDUTRA and continued through its normal progression while she was enlisted." In a November 2016 statement, the appellant expressed her disagreement with the conclusions of the August 2016 examiner. She indicated that her pastor saw her one time in 1989 and told her parents that she "was a normal teenager and not to worry." The appellant reiterated previous assertions that she was psychiatrically normal prior to her first period of ACDUTRA, and she outlined her belief that symptoms of bipolar disorder started during her first period of ACDUTRA. The appellant also noted that depression is not part of her bipolar cycle. In light of the appellant's contentions, the Board remanded the claim in March 2017 in order to obtain an addendum opinion regarding the etiology of the appellant's acquired psychiatric disorder. In an April 2017 opinion, a VA examiner opined that it was not at least as likely as not that any currently diagnosed acquired psychiatric disorder, to include schizophrenia and a bipolar disorder, had its onset during, or was otherwise etiologically related to, the appellant's first period of ACDUTRA from June 23 to November 9, 1993 because there was no evidence of any delusional, psychotic, or manic episodes during that time period that would link such a condition to that period of active duty for training. The examiner also opined that it was less likely as not that the appellant's acquired psychiatric disorder had its onset prior to her first period of ACDUTRA in 1993 because no evidence indicated that she suffered from any manic or psychotic symptoms prior to the first period of ACDUTRA. The examiner specifically noted the appellant's June 2009 letter indicating that she never experienced any psychiatric symptoms prior to her first period of ACDUTRA and outlining symptoms she experienced during her first period of ACDUTRA. However, the examiner also noted that during the August 1997 VA examination, the appellant reported that she first sought therapy at Iowa State in 1994 and that her first major episode was in late 1995 or early 1996 with subsequent hospitalization, which were both after her first period of ACDUTRA. Regarding the appellant's April 2016 hearing testimony that mania was evidenced during AIT based on her boundless energy and attention to detail, the examiner indicated that there was no evidence that a health care professional identified that the appellant experienced mania during AIT. The examiner acknowledged that the August 1997 VA examiner stated that the appellant's hypersexuality in AIT "may represent some subtle symptoms of her bipolar disease," however, the examiner noted that the statement was speculative. The examiner also opined that it was not at least as likely as not that the appellant's acquired psychiatric disorder, to include schizophrenia and a bipolar disorder, was aggravated by the appellant's second period of ACDUTRA in August 1996. The examiner noted that the appellant had already experienced a psychiatric hospitalization before the second period of ACDUTRA and had another hospitalization after the second period of ACDUTRA, which was indicative of similarity in functioning prior to and after the second period of ACDUTRA. The examiner also indicated that the second hospitalization, after the second period of ACDUTRA, matches the appellant's functioning prior to the second period of ACDUTRA and does not indicate permanent aggravation. The examiner further noted that the February 1997 letter from J.T., M.D, indicated that the appellant "experienced good results with mood stabilizers and antipsychotics and their [sic] was a fair long-term prognosis," and that the August 1997 VA examination report showed that the appellant was doing well and was symptom free. The examiner indicated that "[t]hese statements do not indicate a deterioration or permanent aggravation resulting from her 2nd period of ACDUTRA." The examiner further noted that the appellant's condition was first evident in late 1995 or early 1996 and that, since then, she has had "multiple episodes of mania and psychosis, often requiring hospitalization." The examiner noted the appellant's father's statements that the 1996 military training may have aggravated the appellant's acquired psychiatric disorder, but the examiner explained that "[i]t appears speculative to indicate her 1996 military training was the source of permanent aggravation (which her father speculates that military training might have been too much for her to handle) as other providers (see Boone Hospital Center document from June 2002) indicate a deterioration in conjunction with multiple stressors-taking a new job, a new environment-that had nothing to do with the military." C. Analysis As an initial matter, the Board notes that the appellant has been diagnosed with acquired psychiatric disorder, including schizophrenia and a bipolar disorder. As such, the Board finds the current disability element is established. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). However, after review of the foregoing evidence, the Board finds that the preponderance of the evidence is against a finding that the appellant's acquired psychiatric disorder was incurred or aggravated during a period of ACDUTRA. Regarding the appellant's first period of ACDUTRA from June 1993 to November 1993, service treatment records from that period do not contain any complaints or treatment for any psychiatric symptoms. Additionally, military personnel records show that the appellant was awarded for exemplary performance during her first period of ACDUTRA and again in April 1995. The first medical evidence of an acquired psychiatric disorder was the February 1996 hospitalization for a psychotic episode, which the appellant and her friends reported had started two to three months earlier and possibly related to her father's remarriage. The record fails to show any evidence that the appellant was serving in an ACDUTRA capacity in February 1996 or for the two to three months prior to February 1996. The Board acknowledges the appellant's assertions that she first experienced subtle symptoms of mania during her first period of ACDUTRA in 1993, as evidenced by her competitiveness, hypersexuality, boundless energy, and exemplary performance. See April 2016 Hearing Transcript. The Board also acknowledges the appellant's contentions that she had racing thoughts, paranoia, delusions, and insomnia during her 1993 period of ACDUTRA, but she was too nervous and stressed to request sick-call. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that questions regarding the onset, diagnosis, and etiology of psychiatric disorders such as schizophrenia and bipolar disorder are complex and medical in nature. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are 'medical in nature'); 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). The Board also acknowledges that the appellant was a medic in service. This background must be taken into account when evaluating her opinions. See Goss v. Brown, 9 Vet. App. 109, 114-15 (1996); YT v. Brown, 9 Vet. App. 195, 201 (1996); Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Nevertheless, in evaluating the probative value of her medical statements, the Board may look at factors such as the individual knowledge and skill in analyzing the medical data. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (holding that a nurse's statement may constitute competent medical evidence where the nurse has specialized knowledge regarding the area of medicine or participated in treatment). Here, there is no evidence that the appellant has the specific medical expertise in the field of psychiatry needed to render a competent opinion on the specialized, complex medical issues that are the subject of this appeal, such as a diagnosis or etiology of an acquired psychiatric disorder. Specifically, the appellant has not demonstrated any medical knowledge, training or experience that would allow her to recognize such during service or identify its cause(s). See DSM-5 ("It requires clinical training to recognize when the combination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges"); see also Clemons v. Shinseki, 23 Vet. App. 1at 6 (2009) (stating that it "is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (holding that "PTSD is not the type of medical condition that lay evidence . . . is competent and sufficient to identify"). Moreover, any recent lay assertions from the appellant regarding symptom onset during her first period of ACDUTRA are less credible than the contemporaneous treatment records, which contradict such lay statements. In this regard, despite the appellant's assertions that she first experienced psychiatric symptoms during her 1993 period of ACDUTRA, service personnel records reflect that the appellant was awarded for her performance in November 1993 and April 1995, which is somewhat inconsistent with her later statements about symptom onset. Additionally, when the appellant was first hospitalized in February 1996, she and her friends described a symptom onset of two to three months prior, and during the November 2008 VA examination, the appellant reported that her first "episode" occurred in February 1996. See Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010) (upholding Board finding that vague and inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence). The appellant's more recent statements about symptom onset appear to be inaccurate recollections of past events, which are much less reliable than more contemporaneous descriptions at that time. In reaching this conclusion, the Board is not asserting that the appellant is lying. Rather, the Board finds that such statements are inaccurate recollections of a history many years earlier, when compared against the service records and contemporaneous post-service treatment records. Given the appellant's unreliability with accurately reporting timelines and events to treating professionals, the inconsistencies discussed above, and her personal interest, the Board finds that the appellant's reports that she experienced symptoms of a psychiatric disability during her first period of ACDUTRA service are not credible. See Buchanan, 451 F.3d at 1336-1337 (the lack of contemporaneous medical records, the significant time delay between the affiants' observations and the date on which the statements were written, and conflicting statements of the Veteran are factors that the Board can consider and weigh against an appellant's lay evidence); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore an appellant's testimony simply because the appellant is an interested party; personal interest may, however, affect the credibility of the evidence). It is important to point out that the Board does not find that the Veteran's lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (quoting Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Rather, the current lay statements are found to lack credibility because they are inconsistent with and directly contradicted by other lay and 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); Caluza 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). The Board finds the April 2017 VA opinion that the appellant's acquired psychiatric did not have its onset during her first period of ACDUTRA highly persuasive to the issue at hand. Here, the examiner acknowledged and accepted the appellant's reports of experiencing subtle symptoms of mania in service; however, the examiner explained why the acquired psychiatric disorder nonetheless more likely had its onset after the appellant's first period of ACDUTRA. Moreover, in the present case, as discussed in detail above, the Board has found that the appellant's lay statements regarding onset to not be entirely credible. Implicit in the examiner's rationale was that if the appellant's symptoms had been significant, she would have sought treatment earlier. Additionally, "there is no reasons or bases requirement imposed on examiners." Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Rather, an adequate medical report must rest on correct facts and reasoned medical judgment so as to inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports. See Nieves-Rodriguez, 22 Vet. App. at 304 (2008) (holding, in the context of weighing one medical opinion with another, that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion ... that contributes probative value to a medical opinion"). Overall, the April 2017 VA medical opinion was thorough, supported by an explanation, based on a very thorough review of the claims folder, and full acknowledgement of the appellant's lay statements regarding the onset of her symptoms, and it is accompanied by a sufficient explanation and reference to pertinent evidence of record. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Regarding the issue of whether the appellant's second period of ACDUTRA in August 1996 aggravated her acquired psychiatric disorder, the presumptions of soundness and aggravation do not apply in this case as a matter of law, and the probative evidence of record weighs against a finding that the appellant's acquired psychiatric disorder was aggravated beyond its natural progression by any event or injury during her second period of ACDUTRA service. As relevant to this particular aspect of the appellant's claim, a preexisting disease or injury will be found to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 U.S.C.S. § 1153; 38 C.F.R. § 3.306 (a). Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). A temporary or intermittent flare-up of a pre-existing disease also does not constitute aggravation. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Board finds the April 2017 VA opinion to be highly probative on this issue. The discussion accompanying his opinion reflects that it was based on a thorough review of the claims file, and it is consistent with the evidence of record. Moreover, the examiner provided a clear, detailed rationale for the conclusions reached. Accordingly, it is entitled to great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). There is no competent medical opinion of record that contradicts the April 2017 VA opinion. Although the Board does not question the appellant's sincere belief that her acquired psychiatric disorder permanently worsened following her August 1996 period of ACDUTRA, her opinion on that matter is not probative and persuasive evidence. As discussed above, while lay persons are competent to provide opinions on some medical issues, the diagnosis and etiology of an acquired psychiatric disorder is complex. Thus, it falls outside the realm of common knowledge of a lay person, even one, as in the appellant's case, who has had some medical training. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, the mere development of disability while a member of the Army Reserves, alone, is insufficient to warrant service connection for the purpose of disability compensation. In the absence of competent, credible, and probative evidence of an acquired psychiatric disorder having been incurred or aggravated during a period of ACDUTRA, the preponderance of the evidence is against the claim and service connection 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 appellant's claim, that doctrine is not applicable in this case. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and a bipolar disorder, is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs