Citation Nr: 1803105 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 06-03 603A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a heart disability, to include as secondary to an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney-at-Law ATTORNEY FOR THE BOARD S.M. Kreitlow INTRODUCTION The Veteran had honorable active military service from June 1968 to March 1970. The Veteran is deceased and his surviving spouse has been substituted as the appellant in this case. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in July 2005 by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, that denied service connection for PTSD, a left eye conditions, and a heart condition In a September 2008 decision, the Board denied service connection for a left eye condition and remanded for further development the issues of service connection for PTSD and a heart condition, to include as secondary to PTSD. Subsequently, in December 2010, the Board issued a decision denying service connection for an acquired psychiatric disorder, to include PTSD (issue was broadened pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009)) and service connection for a heart disorder, to include as secondary to service-connected disability (based on the Veteran's claim it was secondary to the acquired psychiatric disorder). In March 2011, the Veteran filed a Motion for Reconsideration of the Board's denial of his claim for service connection for a heart disorder, which motion was denied later that month. The Veteran appealed the Board's December 2010 decision to the Court of Appeals for Veterans Claims (Court). In March 2012, pursuant to a Joint Motion for Remand (JMR), the Court vacated the Board's decision and remanded the Veteran's claims to the Board for action pursuant to the JMR. In July 2012, pursuant to the JMR and other findings, the Board remanded the Veteran's claim for service connection for an acquired psychiatric disorder for additional development, and his claim for service connection for a heart disability as inextricably intertwined. In May 2016, a Supplemental Statement of the Case was issued continuing the denial of the Veteran's claims. In September 2016, the Veteran died. Subsequently, in December 2016, the appellant was substituted for the Veteran in this appeal. The appeal was thereafter returned to the Board. The Board notes that the appellant has a separate appeal pending on her claim for service connection for the cause of the Veteran's death that was perfected in November 2017 and the RO sent the appellant a letter in December 2017 advising her it was forwarding her appeal to the Board. However, that appeal is a separate and distinct appeal originated by the appellant, rather than the Veteran, and from a different agency of original jurisdiction than the present appeal before the Board. Consequently, the Board cannot merge that appeal with the appeal presently being decided, and that appeal must be decided in accordance with the Board's normal docketing procedures. FINDINGS OF FACT 1. The evidence fails to establish that the Veteran was diagnosed to have PTSD, but shows that he was diagnosed to have schizoaffective disorder. 2. The Veteran's schizoaffective disorder did not have its onset during his active military service, did not manifest to a compensable degree within one year of his discharge therefrom, and is not otherwise related thereto. 3. The Veteran's arteriosclerotic heart disease is not etiologically related to his active military service. 4. The Veteran did not have confirmed duty or visitation in the Republic of Vietnam or confirmed exposure to an herbicide agent during his active military service. 5. During his lifetime, the Veteran was not service-connected for any disability, to include an acquired psychiatric disorder. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include PTSD and schizoaffective disorder, was not incurred in or aggravated by service, nor may a psychosis be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 2. A heart disability was not incurred in or aggravated by service, was not proximately due to or the result of a service-connected disease or injury, and may not be presumed to have been incurred or aggravated in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Shedden v. Principi, 381 F.3d 1163 (Fed.Cir.2004); Hickson v. West, 12 Vet. App. 247 (1999). For chronic diseases listed in 38 C.F.R. § 3.309(a) the linkage element of service connection may also be established by demonstrating continuity of symptoms since service. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed.Cir. 2013). 38 C.F.R. § 3.307(a)(3) provides for presumptive service connection for chronic diseases that become manifest to a degree of 10 percent or more within 1 year from the date of separation from service. 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson, 581 F.3d at 1313; Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). I. An Acquired Psychiatric Disorder The Veteran initially claimed entitlement to service connection for PTSD due to his active military service in the Navy. In a detailed statement submitted by the Veteran in March 2009, he identified multiple stressful incidents during his time aboard the USS Waller, USS John King, and USS Stickell. The Veteran reported experiencing episodes during service of depression, paranoia, anxiety, mania, wanting to harm others and himself as a result of these episodes in service, as well as health problems involving dental and eye problems he had that caused him infections and headaches that he stated exacerbated his mental health problems. The first question that must be answered on all service connection claims is what, if any, current disability does the Veteran have that may be subject to service connection. Service connection for psychiatric disabilities, including PTSD, requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a). 38 C.F.R. § 4.125(a) requires that diagnoses of mental disorders conform to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (DSM-5 for claims initially certified to the Board on or after August 4, 2014). 38 C.F.R. § 3.304(f). In the present case, the Veteran's claim was initially certified to the Board in April 2007 and, therefore, the DSM-IV is the appropriate diagnostic criteria to apply to his claim even though his claim has been remanded. However, service connection for PTSD requires not just evidence establishing a link between the current diagnosis and the Veteran's military service as normally required for service connection, but rather a link, established by medical evidence, between the Veteran's current symptoms and an in-service stressor, which has been verified by credible supporting evidence that the claimed in-service stressor occurred unless the stressor falls under a specified exception (i.e., related to combat or fear of hostile military or terrorist activity). 38 C.F.R. § 3.304(f). After reviewing the evidence, the Board finds that the preponderance of the evidence is against finding that the Veteran is diagnosed to have PTSD as a result of his active military service. Rather the Board finds the most probative and persuasive evidence establishes that the appropriate diagnosis of the Veteran's current mental health disability is schizoaffective disorder. Private treatment records show initial psychiatric treatment in 1987 with a primary diagnosis of delusional paranoid disorder, persecutory type, and a secondary diagnosis of major depression, recurrent. Thereafter, VA and private treatment records show that the Veteran has continued to receive mental health treatment and received various psychiatric diagnoses, to include anxiety, depression not otherwise specified, and delusional paranoid disorder but his diagnosis was eventually resolved to a diagnosis of schizoaffective disorder. These private treatment records indicate the Veteran's treating physicians consistently related his symptoms of paranoia, anger control issues, hypervigilance and excessive worry to his Delusional Disorder, which is essentially the diagnosis he carried from 1988 until he discontinued his care with this private mental health provider in 2008. The Board acknowledges that VA treatment records show various assessments of the Veteran having a diagnosis of PTSD. However, it does not appear that any of these diagnoses were based upon a full PTSD evaluation of the Veteran, but only on the fact that he reported having symptoms of PTSD. Whenever the Veteran underwent a full mental health evaluation, such as in November 2005 and August 2008, a diagnosis of PTSD was not rendered. It appears this was primarily because the Veteran failed to report any valid stressful events during his military service upon which a diagnosis of PTSD could be based, but also because some of his symptoms could also be explained by his diagnosed schizoaffective disorder. Furthermore, the record shows the Veteran gave inconsistent reports of having PTSD symptoms, even at these two mental health evaluations in November 2005 and August 2008. Significantly, it appears that almost every PTSD screening the Veteran was given was negative despite his reports at times to his mental health treating providers he believed he had PTSD or that he had symptoms of PTSD. To assist in developing the Veteran's claim (which included clarifying his diagnosis), the Veteran was afforded VA examination initially in July 2010. After reviewing the Veteran's claims file and medical record in detail and examining the Veteran, the VA examiner diagnosed the Veteran to have schizoaffective disorder. Although the examiner found that the Veteran reported valid Criterion A PTSD stressors, she stated that the Veteran did not provide information consistent with a diagnosis of PTSD in that he failed to report symptoms consistent with the avoidance criteria (Criterion C) or with hyper-alertness and hyper-arousal (Criterion D). Furthermore, although the Veteran was administered the PTSD Checklist - Military (PCL-M) and scored 55/85 suggestive of PTSD, the examiner stated that this score is just above the cut-off of 50 and, as this instrument is susceptible to minimization and exaggeration, overall, it does not necessarily support or refute a diagnosis of PTSD. The VA examiner reviewed the Veteran's records, provided a discussion with respect the Veteran's claimed PTSD stressors and completed a complete psychiatric examination to evaluate the Veteran's claim of PTSD. The diagnoses of PTSD seen in the VA treatment records prior to 2008 were not associated with any psychiatric treatment records or evaluations, and therefore are of little probative value. Similarly, although the Veteran's VA physician assessed him with PTSD in September 2008, there was no discussion to support such finding, especially of the Veteran's stressors. This physician later amended her diagnosis to exclude PTSD. Thus, this physician's prior diagnosis of PTSD has little to no probative value as well. In the JMR the parties agreed that the Board failed to provide adequate reasons and bases with regards to its discussion of the Veteran's lay testimony. Specifically the parties found that in 2010 the Board erred in determining that the Veteran's lay testimony lacked credibility solely because it is not corroborated by contemporaneous records, citing to Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In addition, the parties agreed the Board failed to consider the Veteran's report that he did not seek treatment for his psychiatric symptoms until 1986 because he was discouraged from doing so by his father and earlier requests for help had been "ignored." Thus, the parties agreed that remand was appropriate for the Board to reconsider the appellant's lay statements on adjudication. In July 2012, the Board remanded the Veteran's claim for further development. In the remand, with regard to the issue of a diagnosis of PTSD, the Board noted that the Veteran, via his attorney, had challenged the July 2010 VA examiner's failure to diagnose PTSD claiming that statements he had made during the examination are inconsistent with the examiner's findings that certain criterion were not met and the examiner failed to address other certain aspects of the criteria and why they were not met. Consequently, as part of the remand for a new medical opinion, the Board requested that the VA examiner address these complained of inadequacies in discussing whether a diagnosis of PTSD is met or not. In May 2013, an addendum was obtained from the July 2010 VA examiner to address the Board's remand. The examiner stated that she is confident that the Veteran did not have both disorders and that the symptoms noted in the report, including isolation, paranoia and anger, are more likely than not part of the schizoaffective disorder and do not appear related to his military trauma. Second, she stated that she specializes in PTSD and would not make a diagnosis that she does not feel is unwarranted as she feels a deep obligation to veterans. The original report was written with a thorough review of all of the information presented to her including his wife's interview, the Veteran's interview, the Veteran's claims file, and also his medical records. If something was not discussed, it was likely a flaw in the template provided to the examiner as, if the symptom is not endorsed, it does not appear mentioned in the report. However, as a licensed psychologist who is bound by an ethic code, the examiner stated that she interviewed to address every symptom in the PTSD diagnosis and also other rule out diagnoses. If a symptom was not endorsed in her reports, it was either because he did not have that symptom or because he had that symptom but it did not appear to be related to PTSD. Nevertheless, she attempted to provide clarification. Initially, as to the Board's concern that the examiner relied on the absence of pertinent symptoms in the service records, the VA examiner stated that, in the body of her July 2010 report, she cited not just an absence of any mention of mental health symptoms in the military records but also noted that psychosocial information provided by the Veteran in the interview suggested that he was functioning well. She stated that typically individuals with severe mental health issues have disturbances in functioning evident from their psychosocial information. In her initial report, she outlined the childhood and military information that was provided by the Veteran and relevant records in the claims file and medical records. However, the information that was provided to her (including her interview with the Veteran) did not provide any information other than being withdrawn as a child that would suggest he had problems functioning. The examiner also noted that it was likely the interview process with the Veteran was affected by his irritation about her line of questions regarding exactly when his mental health symptoms began. She stated that this had to have been pronounced for her to have observed this in an official report. She stated this also indicates that she attempted to address the issue of when symptoms began directly with the Veteran and did not rely solely on service records or the claims file. She stated that she typically weighs the actual interview above all other evidence presented but, in this case, the interview was the primary evidence for determining that the Veteran does not have PTSD as his self-report and presentation in the interview was not consistent with a diagnosis of PTSD but rather consistent with a thought disorder. The VA examiner next addressed the concerns raised in the Board's remand about the Veteran's father encouraging him not to seek help. She stated that she had no evidence that the Veteran was diagnosed with mental health problems in his childhood or in the military. He reported that he was isolative as a child but that he functioned otherwise. He denied in the interview alcohol abuse, drug abuse, behavioral issues, fights with other kids, legal problems, difficulty with academics, and issues with his family of origin as a child. The undersigned cannot know what his father was thinking and it is possible that there was an undiagnosed condition although the Veteran did not report any concerns about his mental health either during the military or as a child in the actual interview with the examiner. She stated that the Veteran's condition as a child is really only relevant if he agreed with the schizoaffective disorder diagnosis as PTSD incurred from his service in the military obviously could not have been present in childhood. PTSD incurred from his childhood could not be diagnosed as he denied childhood traumas that would satisfy criterion A. Isolation as a child would be consistent with a diagnosis in the schizo/mood disorder category. In terms of a psychiatric disorder beginning in the military, his military performance reviews and the information he verbally presented in the interviews suggest he did well interpersonally in the military and this conflicts with both the schizoaffective and PTSD disorder. It is most common for these disorders to cause disruption in interpersonal relationships. The Veteran denied these things himself in the interview with the examiner otherwise they would have been prominent parts of the report. Finally, in regards to the actual symptoms of PTSD that were disputed in the remand, the VA examiner stated that, during the interview, a majority of probing questions regarding the Veteran's symptoms were directly answered by him and his wife. She pointed out that what makes PTSD unique from other mental health disorders is that symptoms of PTSD must stem from a traumatic experience. In other words, the symptoms must relate to the traumatic event. However, in the Veteran's case, many of the symptoms mentioned were not meeting criteria specifically because they had no established link to the traumatic event (either directly or indirectly). She further stated that another complicating factor is that many symptoms of PTSD are very common amongst various mental health concerns. Depression, anxiety, sleep disturbances, paranoia, anger issues, suicidal attempts and ideations, co-occurring addiction, loss of interest, difficulty concentrating, disconnection from others, nightmares, and many other symptoms are also common in many other disorders. Therefore, how they relate to the traumatic event is critical in determining if they represent PTSD or another mental health condition. As for the Veteran and his wife (during her report of the symptoms she noted), they would have been asked to relate the symptoms to his service for every symptom as that is the examiner's standard way of interviewing. The examiner stated that she would have used probing questions especially asking for specific examples to further tease out what is related and not related to the traumatic events. When in doubt as to whether a symptom related or not, her typical practice is to assume it is connected in order to give the benefit of the doubt. Thus, essentially, the examiner stated that, where she did not relate certain symptoms to PTSD, it was because either the Veteran or his wife did not report that such symptom was related to the in-service stressor(s) such that she could distinguish that such symptom was due to PTSD versus another psychiatric disorder such as schizoaffective disorder. In conclusion, the examiner stated that she "DOES NOT opine that the Veteran meets criteria for PTSD." (Emphasis in original.) She stated that the form filled out in July 2010 that makes up the report of the examination is a form provided to the examiner by VA and the reason why so few symptoms appear listed is that they were not present at the levels to indicate PTSD. She further said that it is important to remember that symptoms need to be related to the original trauma as PTSD has many symptoms that overlap with other disorders and, therefore, what distinguishes PTSD from other disorders is that the re-experiencing, arousal, and avoidance symptoms are all about issues connected to the traumatic events. Rather, the examiner opined that the symptoms of schizoaffective disorder better account for the degree of paranoia and depression the Veteran expressed. She stated that the level of paranoia that the Veteran reported is not consistent with PTSD as paranoia and hypervigilance are not the same. Paranoia can be present in PTSD, but as it relates to the trauma. The content of the Veteran's paranoia, however, did not have any connection to his in-service traumatic events nor could he note a pattern of avoidance that represented his fear of triggering traumatic events. He and his wife also noted episodes when he became severely distrusting of her and the "episodic nature" of these delusions appeared consistent with schizoaffective disorder and far less so with PTSD. The Veteran's difficulty concentrating needed to be directly related to the traumatic event, and it appeared that it was not. The examiner noted that difficulty concentrating is also present with depression and other affective disorders, and psychotic symptoms (delusions) also quite likely tend to interfere with concentration. Sleeping a lot to shut off his mind is not consistent with the severe lack of sleep that tends to characterize PTSD as even sleeping medications tend to be insufficient for many with PTSD to get a solid, uninterrupted, nightmare-free night of sleep. Finally, the examiner noted that she did not recall the Veteran reported any sense of a foreshortened future due to his experiences in Vietnam, and, although he did express this concern as he has heart problems, this is not what a sense of foreshortened future means in the diagnostic category of PTSD. In August 2016, the Veteran was afforded a new VA examination by a different examiner. After reviewing the Veteran's claims file and medical records in detail and examining the Veteran, the VA examiner again diagnosed the Veteran to have schizoaffective disorder, specifically depressive type. As for a diagnosis of PTSD, although finding that one of the stressors the Veteran reported at the examination met Criterion A and was related to his fear of hostile military or terrorist activity, the examiner opined that the Veteran does not meet the criteria of a diagnosis of PTSD under either the DSM-IV or the DSM-5. In going through the PTSD criteria in her report, the examiner noted the Veteran reported Criterion B symptoms of re-experiencing in that he has recurrent distressing dreams related to the traumatic event, but no response was provided to Criterion C (persistent avoidance of stimuli), Criterion D (negative alterations in cognitions and mood), and Criterion E (marked alterations in arousal and reactivity). (The Board notes these criteria are set forth in the DSM-5 format, but the VA examiner specifically noted that she evaluated the Veteran under both the DSM-IV and DSM-5 criteria, and therefore the Board does not find any error in the fact that the report is not set forth solely in the DSM-IV criteria as it is able to extrapolate from the report enough information to understand the missing DSM-IV criteria as well.) The examiner further noted in the Remarks section that the Veteran was administered the PTSD Checklist, Military Version (PCL-M), and he scored a 28, which was well below the cutoff score typically associated with the presence of PTSD. He was also administered the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), which was considered valid and was similar to others who often manifest a psychotic or neurotic disorder. In fact, the examiner stated that the profile obtained is consistent with individuals who have a diagnosis of schizoaffective disorder. As for the request that the examiner reconcile the Veteran's reported symptoms that seem consistent with Criterion C and D (avoidance and arousal symptoms), essentially the VA examiner opined that the Veteran's symptoms are more likely accounted for by his schizoaffective disorder as they either pertain directly to the experience of internal stimuli or are not related to any distressing memories of his military stressor. In rendering a medical opinion, the VA examiner sated that a wide range of clinical literature over the years has shown that the great majority of persons exposed to Criteria A stressors, including combat veterans, do not go on to develop full or chronic PTSD. A more typical pattern is immediate symptoms that resolve to baseline or near baseline function over often a period of time. The examiner opined that this Veteran meets this pattern and falls in the majority of those that do not have PTSD despite exposure to Criteria A stressor. This does not minimize or dismiss the events he experienced in service to our country and this service should be honored and appreciated. However, he appears to have had the resiliency and strength to recover from that trauma experience and has not developed full or chronic symptoms of PTSD. Furthermore, the Veteran has reported a long history of symptoms consistent with schizoaffective disorder and the additional mental health difficulties he reported experiencing, including hallucinations, mood changes, detachment from others, difficulty with concentration and irritability, are better accounted for by that diagnosis, not PTSD. After considering all the evidence, the Board finds the May 2013 and August 2016 VA examiner's medical opinion as to the Veteran's current diagnosis (including whether he has PTSD) to be highly probative as they are clearly based upon a review of his entire medical history, a thorough examination of the Veteran, and the VA examiners provided very clear statements of their diagnosis and the reasoning behind why no diagnosis of PTSD is found. Thus, these medical opinions as to what the Veteran's appropriate diagnosis should be are afforded high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.); see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The diagnosis of PTSD seen in the VA treatment records does not appear to be based upon any thorough evaluation of the Veteran. Instead, any thorough evaluation provided, such as in November 2005 and August 2008, resulted in a diagnosis other than PTSD, mostly schizoaffective disorder. The Veteran's treating psychiatrist in September 2008 who diagnosed PTSD does not state the basis upon which such a diagnosis was rendered. Rather the diagnosis appears to have been rendered based upon it having been in his chart previously and his report of symptoms consistent with PTSD, despite the thorough psychological evaluation the Veteran had just undergone the month before where he denied any traumatic events in service and failed to report any real PTSD symptoms. As such, the Board does not find the diagnoses of PTSD in the VA treatment records to have significant probative value. Rather, the Board gives more probative weight to those thorough psychiatric evaluations in the VA treatment records such as in November 2005 and August 2008 that show the Veteran's history and mental status was fully evaluated and assessed. Such evaluations are more consistent with the VA examinations the Veteran has been afforded and supports the diagnosis of schizoaffective disorder as the appropriate diagnosis of the Veteran's current psychiatric disorder. Also supportive of the diagnosis of schizoaffective disorder is a private neuropsychological evaluation conducted in June and July of 2015 that was performed by a non-treating non-VA provider for the purposes of assessing the Veteran's cognition and to provide treatment recommendations. This appears to have been obtained due to concerns regarding a "rapid decline" in the Veteran's memory in recent months and the concern raised for possible dementia at a recent follow-up appointment at VA (although it is unclear whether he was referred by VA or some other medical provider). On the initial report in June 2015, the diagnostic impression was schizoaffective disorder by history and rule out major neurocognitive disorder (dementia). After thorough neuropsychological testing was performed, the final report issued in July 2015 shows the Veteran was assessed to have mild cognitive impairment likely due to small vessel ischemic disease and cognitive symptoms associated with schizoaffective disorder. Significantly, although he was noted to have a history of other diagnoses, to include PTSD, it was found that his current diagnosis was schizoaffective disorder. Furthermore, it was noted that the Veteran had a recent psychotic-like episode that began June 15, 2015 and he was still exhibiting signs of paranoia, suspiciousness and hypervigilance at the time of testing, which symptoms were clearly designated as psychotic symptoms rather than symptoms of PTSD as the Veteran consistently claimed throughout this appeal. Based on the foregoing, the Board finds the most probative and persuasive evidence of record shows that the Veteran's current psychiatric disability is schizoaffective disorder, not PTSD. As a diagnosis of PTSD is not found, service connection for PTSD is not warranted. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Consequently, the Board will proceed to only consider whether the Veteran's diagnosed schizoaffective disorder is related to his active military service. With regard to whether the Veteran's schizoaffective disorder is related to his active military service, the Veteran contends that his mental health symptoms (depression, anxiety, paranoia, homicidal and suicidal ideation, mania, etc.) had their onset during service and continued after service. See March 23, 2009 Correspondence from Veteran. He related that he experienced sleep deprivation during his time on the USS Waller because, initially his bunk was right underneath where they would fired off the three and five inch guns most nights and that would keep him awake and, although he was able to switch to the night shift after a few months, he still was not able to get enough sleep because of people waking him up during the day seeking supplies from the store room, for which he was responsible. He contends that this sleep deprivation caused much of his symptoms, along with the crew being in constant danger as they were along the coast of Vietnam. Also, he related that he never got shore leave or time off and, therefore, he got no relief from his feelings of anxiety or the thoughts of rage and homicide or suicide coming to his mind. He also reported that these problems were aggravated by problems he had with infections in his teeth and his eyesight that was giving him headaches for which he could not get medical attention. Eventually, he had the teeth pulled just before Thanksgiving, but his eyesight problems were never addressed in service (not until 1972 when he was discharged from the Navy Reserve). He further reported that, upon discharge from active duty, he reentered the Reserve for two more years and during this time his mental and physical problems became more evident to many people and himself. He reported he was hot tempered, wanted to run from all establishment, dwelled on revenge, and paranoid. He described himself as having a "hair trigger" toward anger, an explosive temperament, out of control anger, and restlessness. He reported that at times would sleep constantly for days, be really happy and laughing at one time and then instantly change to pure rage then to grief, sometimes secretly cry, and would shake from nerves. He related that he would do reckless things like drive his car over 100 miles per hour without caring, even with his mother in the car His parents were afraid that he would either kill himself or someone else. He reported he had nightmares of conflict in the U.S. Navy and would wake up finding himself standing straight up in bed on his feet and would be panicked about the thought of going back into the Navy. He reported that his Reserve friends were visibly nervous around him and could see he had trouble fitting in and communicating with other people. His mother begged him to seek help, but his father discouraged him, warning him not to get help but "to be a man" and to "straighten up," "just don't think about it," and that it was "shameful" to get "psycho-help." Id. at pp. 1-10. The Veteran has also stated that he tried many times in his life to get help for his mental and physical health but was "dismissed, ignored and not treated even after asking for help and medical care." See April 9, 2010 VA 21-4138. He claimed that stress and improper care left him with a mental problem (along with a whole list of other things). He stated that it took him collapsing of a heart attack and to have a complete mental breakdown before he was taken seriously after many years of searching for proper care. Id. However, the Veteran also admitted that, up until 1986, he only saw a physician a couple of times in his life for sinus and stomach problems. See March 23, 2009 Correspondence from Veteran, p. 22. As for his psychiatric disorder, although the Veteran reported that he had mental health symptoms during service and for a couple of years after service, in 1987, it appears he had a mental health crisis when he became suicidal and homicidal against his co-workers because he believed they were out to get him and put glass in his sandwich. It was at that time that he first sought mental health treatment thanks to his wife to whom he confessed his plan to go into work and kill all his coworkers and himself. He has since received mental health treatment. See March 23, 2009 Correspondence from Veteran, pp. 1-10. In considering whether service connection is warranted in the present case, there is no question that the Veteran has a current psychiatric disability, which has been determined to be diagnosed as schizoaffective disorder. The question remaining is whether the Veteran's current schizoaffective disorder is related to his active military service, especially as he contends in his above statements. After reviewing all the evidence, the Board finds that the preponderance of the evidence is against such a finding. Service treatment records do not reflect the Veteran had any psychiatric problems in service. There are no clinical records showing either symptoms or diagnosis of any mental health problems during the Veteran's active duty. No objective findings of any psychiatric abnormality were found on examination for separation from active duty in March 1970. When the Veteran reenlisted into the Naval Reserve in April 1970, he acknowledged that there had been no material change in his condition since his last examination. The records further show that, in April 1971 and March 1972, he was found medically qualified for 14-day periods of active duty for training (ACDUTRA), and upon release for ACDUTRA in April 1972, he was noted to have been examined and found physically qualified for release. In May 1972, he was examined for discharge from the Navy Reserve. On his Report of Medical History, the Veteran denied having a history of any psychiatric symptoms including frequent trouble sleeping, depression or excessive worry and having nervous trouble of any sort. Upon examination for discharge, no psychiatric abnormalities were noted. In addition, the Veteran's service personnel records do not reflect the performance of an individual who was struggling to perform his duties as the result of mental health issues. The Veteran's performance evaluations for his active duty show he received high marks in all areas of performance while both aboard the USS Waller and the USS Stickell. The performance evaluation from the USS Waller acknowledges that the Veteran was affected by "long hours and poor working conditions." Despite this, his commanding officer stated that it had "not affected his initiative." The review further states the Veteran's behavior was "excellent," he had the "potential to become a very effective leader" and his "overall performance" was "excellent." The Veteran received a similar performance evaluation from his time on the USS Stickell. His commanding officer stated his work was always done well, he was always willing to work, he very rarely had to be told what to do, he wore his uniform with great pride, he got along exceptionally well with his superiors and others he worked with, and he had the ability to be a good petty officer. There is also a performance evaluation for his time on the USS John King but he was not rated as he was on board for less than 90 days. However, it is remarked that he was eligible for advancement so clearly, even though it says he was not observed for evaluation purposes, there was nothing seen in his performance by his superiors that would have prevented him from advancing. Likewise, his performance reviews during his Reserve service clearly do not reflect the level of mental health issues the Veteran expresses in his statements to VA. He received the very high marks (3.8 out of 4.0 in May 1971 and 4.0 out of 4.0 in April 1972). Post-service treatment records do not show mental health treatment until 17 years after active military service. The earliest treatment records showing mental health issues starting in March 1987, although it appears that he may have been in counseling for a little while before that as he reported the onset of depressive symptoms after he underwent a cholecystectomy in June 1986 and there is a March 1987 counseling note indicating earlier sessions. It was after his return to work after this surgery that the Veteran has reported he began having issues with his co-workers harassing him, which culminated with him seeking treatment in March 1987 after an incident in which he alleged that someone put glass in his sandwich. From his report seen in the treatment records, this angered him so much that he thought about taking a gun to work and shooting his co-workers and then himself. Instead, he sought treatment with his primary care physician, who referred him to inpatient mental health treatment. The Veteran's private psychiatric treatment records since March 1987 do not indicate that he reported having any mental health issues during, and in the years subsequent to, his active duty like he has related in his statements to VA. Furthermore, it does not appear that he related his mental health problems to his military service even though the initial mental health treatment records in 1987 show he clearly reported some childhood incidents leading one physician to note an Axis IV stressor of "child abuse survivor." Moreover, the private treatment records show the onset of his mental health problems was related as either the June 1986 surgery or the March 1987 hospitalization. Rather it appears that it is only to VA that the Veteran has related his mental health problems to his active military service, but not until the latter part of 2005. A June 2005 VA Primary Care note includes a diagnosis of PTSD in the Assessments list without explanation. A September 2005 PTSD/Psychiatry Consultation note (referring to a Nurse Practitioner's June 2005 note) shows the Veteran was evaluated for PTSD in June 2005, but he only related the March 1987 glass in the sandwich incident in 1987 as the onset of his pertinent symptoms. However, in November 2005, he again underwent mental health evaluation and it appears it was at this time he first time reported he felt he had PTSD due to being in the Navy. However, the assessment was schizoaffective disorder and major depression. An assessment of PTSD by history was given, but this was based on the Veteran's report that he felt that PTSD was a problem and because he could not readily recall a Criterion A traumatic event and for Criterion C avoidant/numbing symptoms he only reported isolation, which could be related to his schizoaffective disorder. In March 2007, he was seen for follow up. The evaluator noted he was charted with PTSD and schizoaffective disorder with paranoia, more likely the latter. In August 2008, the Veteran was seen for Psychology Consultation due to transfer of his care from his private provider to VA. He reported a history of several episodes of depression, one possible episode of mania and a history of paranoia even when mood is stable. When asked about trauma history, he described military service as very stressful but denied traumatic events. He stated he has nightmares but they are not trauma related. The diagnosis was schizoaffective disorder. Furthermore, the Veteran has been afforded two VA examinations in conjunction with his claim. The initial VA examination was conducted in July 2010 and, as a result of that examination, a diagnosis of schizoaffective disorder was rendered. The VA examiner stated he reviewed the Veteran's claims file, the Veteran's medical records, the Board's remand, Psychometric Tests and Questionnaires, and the Veteran's DD214. Initially, based upon her review of this evidence and examination of the Veteran, the VA examiner opined that there is no objective evidence that the Veteran began to experience his mental illness during the service or that it was incurred by his service in the military. The Board acknowledges that it found in its last remand that this opinion lacks probative value because it relies solely on the lack of corroborating evidence in the Veteran's service treatment records to support his reports of onset of his mental health symptoms in service. Consequently, a second opinion was requested. In May 2013, an addendum was obtained from the July 2010 VA examiner to address the Board's remand. As set forth above, the examiner essentially opined as to whether the Veteran had a diagnosis of PTSD. This medical opinion did not directly address whether the Veteran's schizoaffective disorder had its onset in service. However, the VA examiner did discuss that the psychosocial information provided by the Veteran at the July 2010 VA examination suggested that he was functioning well during his childhood and the military. She stated that typically individuals with severe mental health issues have disturbances in functioning evident from their psychosocial information. In the July 2010 report, she outlined the childhood and military information that was provided by the Veteran and relevant records in the claims file and medical records and stated that the information that was provided (including from her interview with the Veteran) did not provide any information other than his being withdrawn as a child that would suggest he had problems functioning. The examiner also stated that likely the interview process with the Veteran was also affected by his irritation about her line of questions regarding exactly when his mental health symptoms began, which must have been pronounced for her to have noted it in her report. She stated this indicates that she attempted to address the issue of when symptoms began directly with the Veteran and did not rely solely on service records or the claims file as she would have wanted to know about his experiences of depression and anxiety as a child and in the military and would have factored in any self-report he provided during the interview. Furthermore the examiner stated it is possible that there was an undiagnosed condition although the Veteran did not report any concerns about his mental health either during the military or as a child in the actual interview with her. Furthermore, in terms of a psychiatric disorder beginning in the military, she remarked that his military performance reviews and the information he verbally presented during the interview with her suggest he did well interpersonally in the military. It is most common for schizoaffective disorders to cause disruption in interpersonal relationships. The examiner stated that the Veteran denied these things himself in the interview otherwise they would have been prominent parts of the report. Consequently, his self-report during the examination and the service performance reviews conflict with the onset of his schizoaffective disorder being during his military service. The VA examiner who performed the August 2016 VA examination also provided a medical opinion. The examiner stated that her opinion is based upon her clinical experience and expertise, a review of the Veteran's VA medical records, his claims file, the results of a clinical interview, and the Veteran's test results. The examiner opined that the Veteran's symptoms met the criteria for schizoaffective disorder, depressive type, in both the DSM-IV and DSM-5. She stated that, upon questioning, he was unable to give a timeline for when these symptoms started, although he did report being a "loner" through his childhood. However, the examiner explained that, if the Veteran's schizoaffective disorder had been present during his military service, it would have likely been documented as onset is typically associated with needing immediate medical intervention due to the severity of mood change and persistence of hallucinations and delusions, but the Veteran's military health and personnel records reflect no such concerns during his military service. Therefore, the VA examiner opined that the Veteran's diagnosis of schizoaffective disorder, depressive type, was less likely than not incurred in or caused by the claimed in-service stressor related event (or generally, that the claimed condition was less likely than note incurred in or caused by the claimed in-service injury, event or illness). After considering all this evidence, the Board finds the most competent, credible, probative and persuasive evidence does not support the Veteran's claim that his schizoaffective disorder had its onset during his active military service or is otherwise related thereto. The contemporaneous service records, both medical and personnel, fail to provide any indices that the Veteran had any psychiatric disorder during his active duty or his two-year period with the Reserve immediately after his active duty. According to the VA examiners, this is significant because schizoaffective disorder would affect the Veteran's interpersonal relationships and would require immediate medical attention for disturbances in mood and persistent hallucinations and delusions and such should have been reflected either in the Veteran's report during his examination or in his military records, but neither was the case. Instead, the Veteran merely reported being a "loner" during his childhood, but failed to report on examination any interpersonal problems, or for that matter any mental health problems, during his military service. The VA examiners clearly found the lack of evidence in the contemporaneous records to be a significant indication that the Veteran's schizoaffective disorder did not have its onset during service. The August 2016 VA examiner even acknowledged that the Veteran most likely had mental health symptoms related to the stressors he was exposed to during his service in the combat zone in Vietnam but, like a lot of soldiers, he adjusted well to those afterward and those were not related to his schizoaffective disorder. Rather, she opined that "if the Veteran's schizoaffective disorder had been present during his military service, it would have likely been documented as onset is typically associated with needing immediate medical intervention due to the severity of mood change and persistence of hallucinations and delusions," which sounds more consistent with the episode that led to his initial hospitalization in March 1987 given his reports that, since a gallbladder surgery, he struggled with depression and the persistent delusion that his co-workers were out to get him, were harassing him, and ending with them putting glass in his sandwich leading to suicidal and homicidal ideation for which he was hospitalized. The Board acknowledges that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (quoting Layno v. Brown, 6 Vet. App. 465, 469 (1994)); see Jandreau, 492 F.3d at 1377 (holding that whether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board). If the lay evidence is competent, the Board must weigh the competent lay evidence against the other evidence of record in determining credibility. Buchanan v. Nicholson, 451 F.3d 1331, 1334-37 (Fed. Cir. 2006). However, the absence of corroborating records is an insufficient basis on which to find lay statements not credible. Id. at 1337 (although the absence of corroborating or contemporaneous evidence may be a factor to consider, "the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Rather, the Board must "first establish a proper foundation for drawing inferences against a claimant from an absence of documentation." Fountain v. McDonald, 27 Vet. App. 258, 272 (2015); see Horn v. Shinseki, 25 Vet. App. 231, 239 (2012) (absence of evidence cannot be taken as substantive negative evidence without "a proper foundation . . . to demonstrate that such silence has a tendency to prove or disprove a relevant fact"). An example of such a foundation would be whether or why it would be expected that the service treatment records of veterans in the appellant's situation would normally note the claimed condition during service. The credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, and consistency with other evidence, including weighing the contemporary medical evidence against lay statements. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996), superseded in irrelevant part by statute, VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). In weighing contemporaneous evidence as to a veteran's functioning during military service against recent post hoc statements made in support of a claim for benefits, the Board may assign more weight to the contemporaneous service records as they were generated with a view towards ascertaining the veteran's then-contemporaneous state of physical and mental readiness and are official records. Both types of evidence in this matter, and in general in the law, are accorded a high degree of probative value, especially opposed to those generated during the course of a veteran's current attempt to secure service-connected compensation. See, e.g., Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (Observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision); see also Flynn v. Brown, 6 Vet. App. 500, 503 (1994). Clearly the VA examiners believed that there was clinical significance in the absence of evidence of interpersonal problems and treatment for mental health issues in the contemporaneous evidence that could not be overcome by the Veteran's lay statements. They clearly believed that the absence of such documentation in the contemporaneous evidence was sufficient to indicate the Veteran's schizoaffective disorder did not have its onset during the Veteran's active duty when considered with the other evidence, including their interview with the Veteran, which notably his statements during were inconsistent with those submitted to VA in support of his claim. Moreover, the Board finds that the Veteran's denial of mental health symptoms on the May 1972 Report of Medical History is an affirmative statement by him that he did not have such symptoms at that time that directly contradicts his current statements made in support of his claim that he did. As the Veteran had a duty to truthfully report his then mental health status or history of on having such mental health symptoms on such report, this contemporaneous statement of present health carries much more weight than the Veteran's post hoc statement made 37 years later in support of a claim seeking monetary benefits, especially since such statement was made after a psychotic episode in which he "tried to assemble disparate facts from the past to make sense of them" and it was only thereafter that the Veteran began relating his mental health issues to his military service and filed his claim for service connection. See March 2004 private mental health treatment record. Likewise, the lack of objective findings of any psychiatric abnormalities on examinations in March 1970 and May 1972 speak against the Veteran having any mental health issues of clinical significance at that time. Furthermore, the lack of mental health treatment for 17 years after the Veteran's discharge from active duty and the many years even after the onset of mental health treatment (18 years) until the first report from the Veteran relating his mental health problems to his military service is evidence tends to disprove the assertion that the Veteran's mental health problems were incurred during his active military service. Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed.Cir. 2000), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the veteran's health and medical treatment during and after military service); see also Horn v. Shinseki, 25 Vet. App. 231, 240 n.7 (2012) (stating that, when the Board uses the absence of evidence as negative evidence, there must be "'a proper foundation . . . to demonstrate that such silence has a tendency to prove or disprove a relevant fact.'") Moreover, the Board finds that the Veteran's performance evaluations are inconsistent with the Veteran's reports of his mental health problems during his active military and Reserve service, especially his reports of increasing mental health symptoms manifesting into reckless behavior, uncontrollable emotional outburst, anger issues, fear or disrespect for authority, etc., after his separation from active duty during his time in the Reserve from 1970 to 1972. These records clearly show the Veteran was highly functioning during his time on both active duty and while on ACDUTRA during his Reserve service. These records also show he clearly had no difficulty with interpersonal relationships, especially during his active duty. The review from the USS Waller even acknowledges that the Veteran was under a high stress situation and yet he was commended for it not affecting his initiative and for being an excellent performer and having excellent behavior. This does not sound like someone who was having the level of mental health symptoms that the Veteran described in his March 2009 statement, and especially not for someone with the onset of schizoaffective disorder. This finding is supported by the May 2013 VA medical opinion in which the examiner stated that the Veteran's military performance reviews suggest he did well interpersonally in the military, which conflicts with the suggestion that the onset of his schizoaffective disorder being during service. In fact, the examiner stated that it is common for schizoaffective disorder to cause disruption in interpersonal relationships, but the Veteran actually denied having interpersonal relationship problems during the military in his interview with her. Thus, his self-report at the VA examination and the service performance reviews indicate he did well in the military. Moreover, the August 2016 VA examiner also stated that, if symptoms of schizoaffective disorder had been present during the Veteran's military service, this would have likely been documented as onset is typically associated with needing immediate medical intervention due to the severity of mood change and persistence of hallucinations and delusions. However, the Veteran's military and personnel records reflect no such concerns during his military service. The Veteran's report at the November 2005 mental health evaluation that he has had had many potentially destructive behaviors (poor impulse control, driving fast, etc.) since returning from Vietnam (of which the Veteran also reported in his March 2009 statement in support of his claim), and that such symptoms have interfered with his ability to hold a job as he had little social skills and rebelled against most authority, sometimes in a passive aggressive manner, is inconsistent with the evidence that clearly demonstrates that, until March 1987, the Veteran was employed for 22 years with the same employer (since September 1966, which was prior to his period of active duty) and had achieved the position of supervisor. As to the Veteran's reports of having potentially destructive behaviors such as poor impulse control and driving too fast, he reported at the July 2010 VA examination that, prior to entry into service, he liked to drag race. Notably, at this examination he did not report that his desire to drive fast worsened after service. Thus, it would appear that he has always had an interest in driving fast and it is questionable that this behavior was present prior to service. Moreover, the Board finds it significant that the Veteran neither filed a claim for service connection for his psychiatric disorder nor did he start relating his mental health problems to his active military service until after May 2004. According to his private treatment records, in March 2004, he suffered a severe psychotic episode in which he became delusional and paranoid. He tried to assemble disparate facts from the past to make sense of them. As his wife put it, he was trying to relate things together in his past that just were not relatable. See Private mental health treatment note dated May 14, 2004. Consequently, the Board finds that the weight assigned to the Veteran's statements submitted in support of his claim for service connection is reduced because the credibility of such statements are affected by the inconsistencies between them and the contemporaneous medical evidence and what he reported at the two VA examinations, especially given the lapse of time (approximately 37 years) between the Veteran's statements and when the events occurred. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than a discredited history as recounted by a Veteran many years later, long after the fact). Furthermore, given the lapse of time and other things such as the effect of his psychiatric disorder (e.g. the March 2004 psychotic episode), it is possible the Veteran's recollections may simply be mistaken due to the fallibility of human memory for events that occurred decades ago. This is consistent with the law's view of memory in general. See generally, Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). The only medical opinions of record addressing the existence of a nexus relationship are the VA examiners opinions that the Veteran's schizoaffective disorder is less likely than not related to his military service. After reviewing these opinions, the Board finds them to be highly probative and persuasive as to the question of whether the Veteran's current schizoaffective disorder is related to his military service, especially when read together. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.); see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). These opinions are based upon a review of the Veteran's claims file, his contentions, an interview of him and his spouse, his military records and his post-military mental health treatment records. Both VA examiners provided detailed examination reports and medical opinions explaining what evidence they reviewed, the information obtained during the interviews, and their the bases of their opinions. Both VA examiners attempted to address the Board's July 2012 remand concerns (even the August 2016 examiner even though such concerns where not of as much importance given the lapse in time) and both did their best to answer the questions raised by the Board. Thus, the Board finds that substantial compliance with the Board's July 2012 remand has been met. Substantial compliance with a remand order, not strict compliance, is required. See Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1999). Even if the examiners did not fully address every detail, they clearly tried to address the heart of the requests made. Furthermore, any questions asked that were not answered, the Board finds to be superfluous and the answers would not change the outcome of the opinions given or the outcome of this decision and, therefore, to remand for compliance would be a waste of resources. Finally, the VA examiners provided well-articulated, factually accurate rationales explaining the bases of their opinions. Even if not all the evidence was discussed or the rationale maybe lacks specificity, the Board finds these opinions, when read as a whole with the examiner's report, sufficient to express a full and understandable opinion on all aspects of the Veteran's claim. Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012) (there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file, and a VA examination report "must be read as a whole" to determine an examiner's rationale). The Veteran has not provided an opposing medical opinion and he has not shown that he is competent to rebut the VA examiners' medical opinions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnoses). Furthermore, neither he nor the appellant has cited to record evidence indicating that the examiners were incompetent, had erroneous facts, or misinformed the Board. See Rizzo v. Shinseki, 580 F.3d 1288, 1291 (Fed.Cir.2009). Moreover, if the opinion is merely lacking in detail, then it may be given some weight based upon the amount of information and analysis it contains. See Nieves-Rodriguez, 22 Vet. App. at 302; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (citing United States v. Welsh, 774 F.2d 670, 672 (4th Cir.1985) ("The probative value of evidence is its tendency ... to establish the proposition that it is offered to prove."). "VA is not permitted to completely ignore even an 'inadequate' opinion or examination, whether it is in favor or against a veteran's claim." Monzingo, 26 Vet. App. at 107. Hence, the Board finds that the preponderance of the evidence is against findings that service connection is warranted as the competent, credible, probative and persuasive evidence fails to establish that the Veteran's current schizoaffective disorder either had its onset during his active military service or is otherwise related to such service. Finally, the Board acknowledges that schizoaffective disorder is a psychosis that is subject to presumptive service connection if it manifested to a compensable degree within one year of the Veteran's separation from active military service. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a), 3.384. However, in the present case, there is no objective evidence to demonstrate the Veteran had a psychosis that manifested to a compensable degree within one year of his discharge from active duty in March 1970. In fact, shortly after his discharge from active duty, the Veteran reenlisted into the Naval Reserve and served another two years therein. He was examined in April 1971 and March 1972 for entry into his two-week periods of ACDUTRA without notation of any mental health problem. The Veteran's lay statements are simply not sufficient to establish the present of a psychosis within one year of his discharge from active duty. Moreover, the VA examiners have clearly opined that the Veteran's military service records do not show the onset of his schizoaffective disorder was during his military service. The examiners clearly reviewed and considered the Veteran's Reserve records in rendering such an opinion. Therefore, the Board finds that presumptive service connection for a psychosis is not warranted. Consequently, although not specifically rendering an opinion that the Veteran's schizoaffective disorder did not manifest to a compensable degree within one year of his discharge from active duty, the Board finds that it is inferred in their medical opinions as their rationales clearly state that his military records, including his Reserve records, do not demonstrate an onset of the Veteran's schizoaffective disorder. In conclusion, after considering all the evidence of record, the Board finds that the preponderance of the evidence is against finding that service connection for an acquired psychiatric disorder, to include PTSD and schizoaffective disorder, is warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. II. A Heart Disability During the pendency of this appeal, in accordance with authority provided in 38 U.S.C. § 1116, the Secretary of Veterans Affairs announced his decision to establish presumptions of service connection, based upon exposure to herbicides within the Republic of Vietnam during the Vietnam era, for three new conditions: ischemic heart disease, Parkinson's disease, and hairy cell leukemia and other B cell leukemias. VA's final regulation was issued on August 31, 2010. See 75 Fed. Reg. 53202 -53216 (Aug. 31, 2010). In February 2011, the Veteran requested reconsideration of his claim for service connection for a heart condition on the basis that a May 2004 radiology report states that "ischemia is suggested" and his receipt of the Vietnam Service and Vietnam Campaign Medals are proof of his Agent Orange exposure, thereby asserting that he has ischemic heart disease that is subjecting to presumptive service connection based upon exposure to herbicide agents in Vietnam. A veteran, who had active service in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The presumption of herbicide exposure is warranted for service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam (emphasis added). 38 C.F.R. § 3.307(a)(6)(iii) (2010); see also Haas v. Nicholson, 20 Vet. App. 257 (2006), rev'd sub nom. Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008), cert. denied, 77 U.S.L.W. 3267 (Jan. 21, 2009) (No. 08-525). An opinion of the General Counsel for VA held that service on a deep-water naval vessel off the shores of Vietnam may not be considered service in the Republic of Vietnam for purposes of 38 U.S.C. § 101(29)(A), which defines the Vietnam era as the period beginning on February 28, 1961, and ending on May 7, 1975, and that this was not inconsistent with the definition of service in the Republic of Vietnam found in 38 C.F.R. § 3.307(a)(6)(iii). VAOPGCPREC 27-97 (July 23, 1997). A Veteran must demonstrate actual duty or visitation in the Republic of Vietnam to have qualifying service. Id. Since issuance of that General Counsel opinion, VA has reiterated its position that service in deep-water naval vessels (i.e., "blue water" service) offshore of Vietnam, as opposed to service aboard vessels in inland waterways of Vietnam (i.e., "brown water service") is not included as "service in the Republic of Vietnam" for purposes of presumptive service connection for Agent Orange diseases. See 66 Fed. Reg. 23166 (May 8, 2001) (comments section announcement of final rule adding diabetes to the list of Agent Orange presumptive diseases); see also VA Manual M21-1, IV.ii.1.H.2. Pursuant to the authority granted by the Agent Orange Act of 1991, VA may determine that a presumption of service connection based on exposure to herbicides used in Vietnam is warranted for conditions that VA has found to have a statistically significant association with such exposure. As such, VA has determined that a statistically significant association exists between exposure to herbicides and subsequent development of the following conditions: chloracne, non-Hodgkin's lymphoma, soft tissue sarcoma, Hodgkin's disease, porphyria cutanea tarda (PCT), multiple myeloma, acute and subacute peripheral neuropathy, prostate cancer, cancers of the lung, bronchus, larynx, trachea, Type II (adult-onset) diabetes mellitus, chronic lymphocytic leukemia, AL amyloidosis, Parkinson's disease, ischemic heart disease, and B-cell leukemias, such as hairy cell leukemia. See 38 C.F.R. § 3.309(e). For purposes of this regulation, the term "ischemic heart disease" includes, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina. VA and private treatment records show that the Veteran has current diagnoses of coronary artery disease and arteriosclerotic heart disease and, therefore, has ischemic heart disease for purposes of the presumption of service connection. However, the Board finds that service connection for the Veteran's ischemic heart disease is not warranted because the evidence fails to establish that the Veteran's service meets the requirements to be presumed to be exposed to herbicide agents. The Veteran's Form DD 214 and personnel records show that he served in the Navy aboard the destroyer, USS Waller-DD466, from July 1968 to July 1969. The Veteran received the Vietnam Campaign Medal for service in the Vietnam combat zone during the months of October 1968 through March 1969. He also received the Vietnam Service Medal. Although personnel records clearly show that the Veteran served aboard the USS Waller, this was a "blue water" Navy ship in the waters off the shore of the Republic of Vietnam from October 1968 to March 1969. The response from the U.S. Army and Joint Services Records Research Center (JSRRC) confirmed the USS Waller conducted Naval Gunfire Support operations off Qui Nhon and Phan That, Republic of Vietnam, and along the coastline. See June 2010 DPRIS response. Furthermore, it has not been documented that the USS Waller operated in the rivers, canals, estuaries, and delta areas making up the inland waterways of the Republic of Vietnam or docked to shore in within one of the bays with sending men to shore. Moreover, the Veteran's personnel records do not confirm any duty or visitation in the Republic of Vietnam and the Veteran even complained of the fact that he was not given shore leave as one of his stressors for his psychiatric problems during this period of service. The Veteran has not submitted any additional evidence to show he had actual duty or visitation in Vietnam, not even his own lay statement. The Board acknowledges that the Veteran can attest to factual matters of which he has first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); however, the Veteran has not identified any specific incidents of actual duty or visitation in Vietnam, nor has he provided any other evidence showing that he was exposed to an herbicide agent in service. Absent qualifying service in Vietnam to establish presumptive exposure to herbicide agents, and absent corroborating evidence of actual exposure to herbicide agents, the Board finds that there is no basis for presumptive service connection due to herbicide exposure. See 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). However, the Veteran is not precluded from establishing service connection for a diagnosed disability with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). The Veteran has also claimed that his current heart disability is secondary to his acquired psychiatric disorder. Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service- connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The record shows that the Veteran is not currently service connected for any disabilities. Thus, secondary service connection is not warranted and the Board will consider the Veteran's claim on a direct basis only. Service treatment records do not reflect any complaints, diagnoses, or treatment related to a heart condition. The earliest post-service evidence of a diagnosis of a heart disability was approximately 33 years after the Veteran's separation from active service. Consequently, the Board finds that the absence of a heart condition in the service treatment records or of persistent symptoms of such a disorder at separation, along with the first evidence being many years later, tends to disprove the assertion that the Veteran's heart disability was incurred during his active military service. Service incurrence may be rebutted by the absence of medical treatment for the claimed condition for many years after service. Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed.Cir. 2000), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the veteran's health and medical treatment during and after military service); see also Horn v. Shinseki, 25 Vet. App. 231, 240 n.7 (2012) (stating that, when the Board uses the absence of evidence as negative evidence, there must be "'a proper foundation . . . to demonstrate that such silence has a tendency to prove or disprove a relevant fact.'") Hence, the preponderance of the evidence is against finding that a heart disability was incurred in service or that it manifest within one year of the Veteran's separation from active service or that it is related to service. In light of the foregoing, the Board finds that service connection for a heart disability is not warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and schizoaffective disorder, is denied. Entitlement to service connection for a heart disability, to include as secondary to an acquired psychiatric disorder, is denied. ____________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs