Citation Nr: 1713761 Decision Date: 04/27/17 Archive Date: 05/05/17 DOCKET NO. 11-24 277 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a traumatic brain injury (TBI). 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include depressive disorder, adjustment disorder, and dissociative disorder. 4. Entitlement to a disability manifested by joint pain, to include as due to an undiagnosed illness. 5. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from February to June 1990 and from September 1990 to August 1991, including in the southwest Asia theater of operations in the Persian Gulf War. He had several periods of active duty for training (ACDUTRA) in October 1991, November 1992, December 1993, and in April, July, and August 1995. He also had additional unverified U.S. Army Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the Veteran's claims of service connection for a TBI, PTSD, a disability manifested by joint pain, to include as due to an undiagnosed illness (which was characterized as undiagnosed Gulf War Syndrome (claimed as joint pain)), and for bilateral hearing loss. The Veteran disagreed with this decision in December 2009. He perfected a timely appeal in August 2011. The Veteran appointed his current service representative to represent him before VA by filing a signed VA Form 21-22 in June 2013. In June 2014, the Board remanded this matter to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed that the AOJ attempt to obtain the Veteran's complete service treatment records, service dental records, and updated VA treatment records. The Board also directed that the AOJ schedule the Veteran for appropriate examination to determine the nature and etiology of his claimed psychiatric disabilities. The records subsequently were associated with the claims file and the requested examination occurred in July 2014. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board notes that, in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court held that claims for service connection for PTSD also encompass claims for service connection for all psychiatric disabilities afflicting a Veteran based on a review of the medical evidence. The medical evidence indicates that the Veteran has been diagnosed as having depressive disorder, adjustment disorder, and dissociative disorder. Thus, the claims of service connection for PTSD and for an acquired psychiatric disability other than PTSD, to include depressive disorder, adjustment disorder, and dissociative disorder, are as stated on the title page of this decision. This appeal was processed using the Virtual VA (VVA) and Virtual Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. The record evidence shows that the Veteran does not experience any current TBI, PTSD, acquired psychiatric disability other than PTSD, or disability manifested by joint pain in the shoulders, elbows, wrists, hips, or ankles which could be attributed to active service. 2. The record evidence shows that the Veteran's current mild degenerative joint disease of the bilateral knees is attributable to the normal aging process and is not related to active service. 3. The record evidence shows that the Veteran's current bilateral hearing loss is not related to active service or any incident of service. CONCLUSIONS OF LAW 1. A TBI was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2016). 2. PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2016). 3. An acquired psychiatric disability other than PTSD, to include depressive disorder, adjustment disorder, and dissociative disorder, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2016). 4. A disability manifested by joint pain was not incurred in or aggravated by active service, to include as due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1112, 1113, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2016). 5. Bilateral hearing loss was not incurred in or aggravated by active service nor may sensorineural hearing loss be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his or her claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. VA's duty to notify was satisfied by letters dated in October 2009, March 2010, and in April 2011. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the AOJ and the Board, although he declined to do so. Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA also must seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's electronic paperless claims files in VVA and in VBMS have been reviewed. He also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. The Veteran has been provided with VA examinations which address the contended causal relationships between the claimed disabilities and active service. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Service Connection Claims The Veteran contends that he incurred a TBI, PTSD, an acquired psychiatric disability other than PTSD (which he characterized as depression), a disability manifested by joint pain, and bilateral hearing loss during active service. He specifically contends that he was assaulted during active service, resulting in a head injury. He also specifically contends that his unit received enemy SCUD missile attacks while he was deployed to the southwest Asia theater of operations in the Persian Gulf War, causing him to experience PTSD. He further contends that in-service exposure to significant acoustic trauma caused or contributed to his current bilateral hearing loss. He finally contends that an undiagnosed illness initially experienced while deployed to the southwest Asia theater of operations in the Persian Gulf War subsequently caused or contributed to his disability manifested by joint pain. Laws and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection also may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including sensorineural hearing loss (as an organic disease of the nervous system), are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "PTSD is not the type of medical condition that lay evidence...is competent and sufficient to identify." See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat Veterans). If, however, 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. Examples of such evidence include, but are not limited to, statements from family members, and evidence of behavior changes following the claimed assault. 38 C.F.R. § 3.304(f)(3). In Patton v. West, 12 Vet. App. 272 (1999), the Court held that special consideration must be given to personal assault PTSD claims. In particular, the Court held in Patton that the provisions in M21-1, Part III, 5.14(c), which address PTSD claims based on personal assault, are substantive rules which are the equivalent of VA regulations and must be considered. See also YR v. West, 11 Vet. App. 393, 398-99 (1998). The Board notes that M21-1, Part III, Chapter 5, has been rescinded and replaced, in relevant part, by M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. See generally M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. These M21-1MR provisions on personal assault PTSD claims require that, in cases where available records do not provide objective or supportive evidence of the alleged in-service stressor, it is necessary to develop for this evidence. As to personal assault PTSD claims, more particular requirements are established regarding the development of "alternative sources" of information as service records may be devoid of evidence because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities. See M21-1MR, Part III, Subpart iv, Chapter 4, Section H30b. Further, the relevant provisions of M21-1MR indicate that behavior changes that occurred around the time of the incident may indicate the occurrence of an in-service stressor and that "[s]econdary evidence may need interpretation by a clinician, especially if the claim involves behavior changes" and "[e]vidence that documents behavior changes may require interpretation in relation to the medical diagnosis by a neuropsychiatric physician". See M21-1MR, Part III, Subpart iv, Chapter 4, Section H30c. In July 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by relaxing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010) as amended by 75 Fed. Reg. 41092 (July 15, 2010) (providing the correct effective date of July 13, 2010 for the revised 38 C.F.R. § 3.304(f)). Specifically, the final rule amends 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (f)(3) If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The revised § 3.304(f) generally applies to claims of service connection for PTSD appealed to the Board on or after July 13, 2010. Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1)(i). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). A Persian Gulf Veteran is one who served in the Southwest Asia theater of operations during the Persian Gulf War. Id. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d)(2). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. §§ 3.317(a)(2)-(5). Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended. 38 U.S.C.A. §§ 1117, 1118. Essentially, these changes revised the term "chronic disability" to "qualifying chronic disability," and involved an expanded definition of "qualifying chronic disability" to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317. The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined. VAOPGCPREC 8-98 (Aug. 3, 1998). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317. Id. Clinically, the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For compensation purposes, however, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater or where the auditory thresholds for at least three of these frequencies are 26 dB or greater or when speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker, the Federal Circuit overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Fountain v. McDonald, 27 Vet. App. 258 (2015) (adding tinnitus as an "organic disease of the nervous system" to the list of disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a)). Because a TBI, PTSD, an acquired psychiatric disability other than PTSD, and a disability manifested by joint pain all are not recognized explicitly as "chronic" in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to these claims. In contrast, because sensorineural hearing loss (as an organic disease of the nervous system) is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating this claim. It is VA policy to administer the laws and regulations governing disability claims under a broad interpretation and consistent with the facts shown in every case. When a reasonable doubt arises regarding service origin, the degree of disability, or any other point, after careful consideration of all procurable and assembled data, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not prove or disprove the claim satisfactorily. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background and Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claims of service connection for a TBI, PTSD, an acquired psychiatric disability other than PTSD, or for a disability manifested by joint pain. The Veteran contends that he incurred each of these claimed disabilities during active service. Despite the Veteran's assertions to the contrary, the evidence shows that he does not experience any current disability to a TBI, PTSD, an acquired psychiatric disability other than PTSD, or a disability manifested by joint pain in the shoulders, elbows, wrists, hips, or ankles which could be attributed to active service or any incident of service. And, although the Veteran experiences mild degenerative joint disease of the bilateral knees, it is attributable to the normal aging process and is not related to active service. For example, the Veteran's available service treatment records show no complaints of or treatment for any of these claimed disabilities, including after he returned from his deployment to the southwest Asia theater of operations in the Persian Gulf War. These records also indicate that the Veteran's in-service complaints of joint pain in the feet were attributed to bilateral pes planus and bilateral plantar fasciitis. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The post-service evidence also does not support granting service connection for a TBI, PTSD, an acquired psychiatric disability other than PTSD, or for a disability manifested by joint pain. Although the Veteran contends that he continued to experience each of these claimed disabilities after his service separation at the end of his second period of active service, the record evidence again shows instead that he does not experience any current disability due to any of these claimed disabilities which could be attributed to active service or any incident of service. For example, on VA PTSD examination in September 2009, the Veteran reported an in-service fall off of a truck as a result of an explosion from an enemy SCUD missile attack while deployed to the southwest Asia theater of operations in the Persian Gulf War in approximately February 1991. He also reported experiencing military sexual trauma in active service. He had a normal relationship with his parents and siblings growing up, made friends easily, and got along well with others. He had been married to his first wife for 3 years but divorced her. He also had been married to his second wife for 2 years but had been separated from her for 18 months. He had a pretty good relationship with his 2 children. He had no friends and "keeps to himself all the time...He claims to do 'absolutely nothing' for leisure." Mental status examination of the Veteran in September 2009 showed he was clean, casually dressed, neatly groomed, full orientation, unremarkable psychomotor activity, speech, thought process, and thought content, no delusions, hallucinations, sleep impairment, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, or suicidal or homicidal ideation, good impulse control, an ability to maintain minimum personal hygiene, and normal memory. The VA examiner stated that, although the Veteran initially was not observed to be hypervigilant, he acted hypervigilant after being told of the purpose of the examination. He also had no observable symptoms of anxiety or hypervigilance after 5 minutes of testing. This examiner also stated that the Veteran appeared to be exaggerating his symptoms. He concluded that the Veteran did not met the diagnostic criteria for valid stressors or for a diagnosis of PTSD. This examiner also opined that it was less likely than not that the Veteran's claimed PTSD was related to active service. The rationale for this opinion was that the Veteran did not meet the diagnostic criteria for PTSD, a review of the Veteran's claims file, clinical evaluation, and a review of recent research, psychological testing, and the diagnostic criteria. There was no Axis I diagnosis. On VA joints examination in October 2009, the Veteran's complaints included constant joint pain since 1994 affecting his wrists, elbows, knees, ankles, and hips. He was left-hand dominant. Physical examination showed a normal gait, no evidence of abnormal weight-bearing, no loss of a bone or part of a bone, and no inflammatory arthritis. X-rays of the elbows, wrists, and ankles were normal although an old avulsion fracture involving the dorsal aspect of the distal right talus also was seen. X-rays of the knees showed mild medial compartment joint space narrowing. The VA examiner stated that all of the Veteran's joints had an essentially normal range of motion with slight reductions noted on flexion of the elbows, hips, and knees, and a slight reduction in shoulder abduction. The Veteran "has a very muscular build and continues to exercise on a regular basis." The Veteran's very mild and limited bilateral knee degenerative joint disease "is most likely a normal aging process." The diagnoses were normal bilateral shoulders, bilateral elbows, bilateral wrists, bilateral hips, bilateral ankles, and mild degenerative joint disease of the bilateral knees. Following VA Gulf War Guidelines examination in October 2009, the VA examiner opined that the Veteran had no undiagnosed illnesses. The rationale for this opinion was a review of the Veteran's service treatment records and post-service VA treatment records. On VA PTSD examination in June 2011, the Veteran "appeared angry and reluctant to engage in this interview." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. "Throughout the interview, the Veteran responded to questions in very few words and did not offer to elaborate. Long latencies between inquiries and his responses appeared to express anger." The Veteran had been married and divorced twice. He had no friends. The VA examiner stated, "The Veteran did not respond directly to inquiry about stressors. Rather, he expressed strong objections to questions about his experiences." The Veteran identified his claimed in-service stressors as: (1) being sexually assaulted 4 times in November and December 1990 while deployed to the southwest Asia theater of operations in the Persian Gulf War; (2) shooting 2 civilians in January 1991 while deployed to the southwest Asia theater of operations in the Persian Gulf War; (3) seeing dead bodies and body parts "everywhere" in February 1991 while moving supplies through Kuwait in the Persian Gulf War; (4) and witnessing a SCUD missile attack. He denied experiencing depression, mania, generalized anxiety disorder, or panic attacks. The VA examiner stated that the Veteran appeared to be intentionally exaggerating his symptoms. "He endorsed a high frequency of symptoms that are highly atypical in patients with genuine psychiatric or cognitive disorders, suggesting significant over-endorsement of symptoms." Mental status examination of the Veteran in June 2011 showed good hygiene, adequate grooming, appropriately dressed, full orientation, an irritable and angry affect, long latencies of speech "before responding to inquiries" and "very short responses," unremarkable thought content and progression, no evidence or endorsement of tangentiality, circumstantiality, looseness of associations, flight of ideas, suicidal or homicidal ideation, or hallucinations or delusions, and fair judgment and insight. The VA examiner concluded that the Veteran did not meet the diagnostic criteria for a diagnosis of PTSD. This examiner acknowledged that the Veteran had been treated for PTSD but "the receipt of treatment is not a diagnostic criterion for PTSD, nor is there evidence in the published empirical literature that a diagnosis of PTSD is at least as likely as not to be valid because one receives treatment associated with it." This examiner also concluded that there was no evidence to support the Veteran's assertion of in-service military sexual trauma. "While he reported being sodomized in his statement of claim for benefits, he previously reported to a treating provider that he [was] sexually abused by a female officer who [engaged] in bondage with him." There was no Axis I diagnosis. On VA outpatient treatment in December 2011, the Veteran had a dysphoric mood. Mental status examination of the Veteran showed he was dressed appropriately, good eye contact, full orientation, coherent and relevant speech, organized and goal-directed thoughts, no auditory or visual hallucinations, no delusions, reported suicidal ideation but no intent or plan, no homicidal ideation, intent, or plan, and "notable shifts in mood/affect, body posture, and eye contact." The Axis I diagnosis was dissociative disorder, not otherwise specified. In January 2012, the Veteran's complaints included joint pain which he rated as 7/10 on a pain scale, hearing voices, intrusive thoughts, and nightmares. A history of 1 suicide attempt was noted. He denied any current suicidal ideation or plan. Mental status examination of the Veteran showed good grooming, eyes "looking over the room thoroughly during the interview," full orientation, difficulties with long-term memory, "stumbled over much of the history questions," no psychomotor agitation or retardation, "some abnormal or involuntary movements in the shoulder area, like spasms," normal rate and low volume, slow and deliberate speech, blunted thoughts with thought blocking, reported auditory hallucinations, demonstrated suspicious thinking, and fair judgment and insight. The Axis I diagnoses included chronic severe PTSD, major depressive disorder, and cognitive disorder secondary to suspected TBI versus depression. VA mental health treatment plan dated in May 2012 noted that the Veteran's Axis I diagnoses were dissociative disorder, not otherwise specified (military sexual trauma), and recurrent major depressive disorder. Subsequent VA outpatient treatment records dated in 2012-2013 note ongoing treatment for PTSD, dissociative disorder, and major depressive disorder. On VA PTSD Disability Benefits Questionnaire (DBQ) in July 2014, the Veteran reported that he was living part-time with his mother and at other times with female acquaintances. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. Mental status examination of the Veteran showed he was clean, neatly groomed, full orientation, normal speech, thought content and progression within normal limits, no hallucinations, delusions, or grossly inappropriate behavior, concentration and attention and memory within normal limits, no current suicidal ideation but reported past suicidal ideation, no homicidal ideation, and fair judgment and insight. The Veteran denied experiencing any in-service trauma. The VA examiner concluded that the Veteran did not meet the DSM-5 diagnostic criteria for a diagnosis of PTSD. He also concluded that the Veteran did not have a diagnosis of a TBI. He further concluded that no other mental disorder other than PTSD was diagnosed. The Veteran's claimed in-service stressor was not adequate to support a diagnosis of PTSD and was not related to a personal assault or military sexual trauma. This examiner opined that it was less likely than not that the Veteran's claimed PTSD was related to active service or any incident of service. The rationale for this opinion was there were no markers consistent with military sexual trauma in a review of the Veteran's medical records and service personnel records. The rationale also was that the descriptions of the Veteran's behavior in his records was not consistent with military sexual trauma. The rationale further was that a review of the Veteran's VA medical records did not support a diagnosis of PTSD because the PTSD diagnosis of record appeared to be based on an unstructured interview of the Veteran and the medical literature "indicates that the use of a structured interview...is significantly and statistically superior in assessing for PTSD versus an unstructured interview." This examiner acknowledged that the Veteran had been treated for PTSD but "the receipt of treatment is not a diagnostic criterion for PTSD, nor is there evidence in the published empirical literature that a diagnosis of PTSD is at least as likely as not to be valid because one receives treatment associated with it." This examiner also stated that none of the clinicians who diagnosed the Veteran as having PTSD had administered a structured interview, reviewed the claims file, or followed accepted practice guidelines, including VA's best practices manual "in reaching their diagnostic conclusions." A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced a TBI, PTSD, an acquired psychiatric disability other than PTSD, or a disability manifested by joint pain at any time during the pendency of this appeal. Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, there is no evidence of a TBI or a disability manifested by joint pain in the shoulders, elbows, wrists, hips, or ankles at any time during the pendency of this appeal. The Board notes in this regard that the presence of a mere symptom (such as joint pain) alone, absent evidence of a diagnosed medical pathology or other identifiable underlying malady or condition that causes the symptom, does not qualify as disability for which service connection is available. See generally Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The October 2009 VA Gulf War Guidelines examiner specifically found that the Veteran had no undiagnosed illnesses. The October 2009 VA joints examiner concluded that the Veteran's bilateral shoulders, bilateral elbows, bilateral wrists, bilateral hips, and bilateral ankles all were normal. This examiner also attributed the Veteran's mild degenerative joint disease of the bilateral knees to the normal aging process. All of these opinions were fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Although the Veteran was diagnosed as having and treated for PTSD and for an acquired psychiatric disability other than PTSD since his service separation, the more recent evidence (VA PTSD DBQ in July 2014) indicates that the Veteran does not experience any current disability due to either of these claimed disabilities which could be attributed to active service. The July 2014 VA examiner also specifically opined that the prior diagnoses of PTSD in the medical records were not valid for VA purposes. These opinions also were fully supported. See Stefl, 21 Vet. App. at 124. The Veteran finally has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to service connection for a TBI, PTSD, an acquired psychiatric disability other than PTSD, or for a disability manifested by joint pain. In summary, the Board finds that service connection for a TBI, PTSD, an acquired psychiatric disability other than PTSD, or for a disability manifested by joint pain is not warranted. The Board finally finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for bilateral hearing loss. The Veteran contends that in-service hazardous noise exposure caused or contributed to his current bilateral hearing loss. Despite his assertions to the contrary, the record evidence does not support finding an etiological link between his current bilateral hearing loss and active service or any incident of service. For example, the Veteran's available service treatment records show that, at his separation physical examination in May 1990 at the end of his first period of active service, his pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 5 10 5 LEFT 10 5 0 0 5 At his separation physical examination in July 1991 at the end of his second period of active service, the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 5 5 5 LEFT 15 15 5 10 5 The Board again notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. The post-service evidence also does not support granting service connection for bilateral hearing loss. It shows instead that, although the Veteran has complained of and been treated for bilateral hearing loss since his service separation in August 1991 at the end of his second period of active service, it is not related to active service or any incident of service. For example, on VA audiology consult in October 2008, the Veteran's complaints included difficulty hearing. His hearing had worsened gradually for 13 years. Pure tone audiometric testing showed bilateral hearing loss. The diagnosis was bilateral sensorineural hearing loss. On VA audiology examination in July 2010, no relevant complaints were noted. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported in-service noise exposure from combat weapons, including explosions, while in combat. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 30 30 LEFT 25 25 25 30 35 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and 92 percent in the left ear. The VA examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was related to active service. The rationale for this opinion was that a review of the claims file showed normal hearing in both ears at separation from service and in 1996 and a review of relevant medical literature showed no scientific evidence supporting delayed onset hearing loss. The diagnosis was bilateral sensorineural hearing loss. On VA outpatient treatment in October 2012, the Veteran's complaints included difficulty hearing or understanding speech "in work settings as well as normal conversation. This began after experiencing two blast exposures with [loss of consciousness] while deployed." Pure tone audiometric testing revealed hearing within normal limits with the exception of a mild hearing loss at 8000 Hertz in the right ear. The assessment was peripheral hearing essentially within normal limits bilaterally with evident mild problems discriminating speech in noise. Hearing aids were ordered for the Veteran. The Veteran contends that his current bilateral hearing loss is related to active service. The record evidence does not support his assertions. It shows instead that, although the Veteran has complained of and been treated for bilateral hearing loss since his service separation and currently wears hearing aids, his bilateral hearing loss is not related to active service or any incident of service. The July 2010 VA examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was related to active service. This opinion was fully supported. See Stefl, 21 Vet. App. at 124. The Veteran also has not identified or submitted any evidence, to include a medical nexus, demonstrating his entitlement to service connection for bilateral hearing loss. In summary, the Board finds that service connection for bilateral hearing loss is not warranted. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 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"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr, 21 Vet. App. at 309. As noted, the absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements, the Veteran has asserted that his symptoms of a TBI, PTSD, an acquired psychiatric disability other than PTSD, a disability manifested by joint pain, and bilateral hearing loss have been continuous since service. He asserts that he continued to experience symptoms relating to a TBI (dizziness, difficulty standing and walking), PTSD (flashbacks), an acquired psychiatric disability other than PTSD (depression), a disability manifested by joint pain, and bilateral hearing loss after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of any of these claimed disabilities after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of any of these claimed disabilities since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that his disorders began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any relevant history or complaints of symptoms. Specifically, the service separation examination report reflects that the Veteran was examined and he was found to be normal clinically. His in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). He did not claim that symptoms of his disorders began in (or soon after) service until he filed his current VA disability compensation claims. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. 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 has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the record evidence showing no current disability due to a TBI, PTSD, an acquired psychiatric disability other than PTSD, or a disability manifested by joint pain which could be attributed to active service, and the record evidence showing no etiological link between bilateral hearing loss and active service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to service connection for a TBI is denied. Entitlement to service connection for PTSD is denied. Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include depressive disorder, adjustment disorder, and dissociative disorder, is denied. Entitlement to a disability manifested by joint pain, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for bilateral hearing loss is denied. ____________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs