Citation Nr: 18151006 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-38 776 DATE: November 16, 2018 ORDER New and material evidence having been submitted, the claim of entitlement to service connection for a respiratory disability is reopened. Entitlement to service connection for a respiratory disability, to include as due to undiagnosed illness, is denied. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to undiagnosed illness, is denied. Entitlement to service connection for irritable bowel syndrome (IBS), to include as due to undiagnosed illness, is denied. Entitlement to service connection for arthritis of the back, knees, legs, and right ankle, claimed as secondary to posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for PTSD is denied. Entitlement to an effective date prior to February 1, 2015 for the award of additional compensation for the Veteran’s spouse is denied. REMANDED The claim of entitlement to service connection for obstructive sleep apnea is remanded. The claim of entitlement to service connection for alcohol use disorder is remanded. FINDINGS OF FACT 1. Service connection for a respiratory disability was denied in an October 2000 rating decision; the Veteran did not appeal. 2. The evidence added to the record since the October 2000 rating decision is not cumulative or redundant of evidence previously of record, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a respiratory disability, and raises a reasonable possibility of substantiating the claim. 3. A chronic respiratory disability did not result from undiagnosed illness that was shown during active service or thereafter; the evidence is against a finding that a chronic respiratory disability is related to active service or events therein. 4. CFS did not result from undiagnosed illness that was shown during active service or thereafter; the evidence is against a finding that CFS is related to active service or events therein. 5. IBS did not result from undiagnosed illness that was shown during active service or thereafter; the evidence is against a finding that IBS is related to active service or events therein. 6. Arthritis of the back, knees, legs, and right ankle, is not proximately due to a service-connected disability, and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, event, or disease. 7. The Veteran does not have PTSD. 8. The Veteran submitted a request for additional benefits for dependents on January 11, 2015. CONCLUSIONS OF LAW 1. The October 2000 rating decision is final. 38 U.S.C. § 7104(b) (2012); 38 C.F.R. §§ 3.160(d), 20.1103 (2017). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a respiratory disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for service connection for a respiratory disability are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2017). 4. The criteria for service connection for CFS are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2017). 5. The criteria for service connection for IBS are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2017). 6. The criteria for service connection for arthritis of the back, knees, legs, and right ankle are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a)-(b), (d), 3.307, 3.309(a) (2017). 7. PTSD was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1154(b) (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 8. The criteria for entitlement to an effective date prior to February 1, 2015 for the award of additional compensation for the Veteran’s spouse have not been met. 38 U.S.C. §§ 1115, 5101, 5110 (2012); 38 C.F.R. §§ 3.4, 3.31, 3.400, 3.401 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service incurrence or aggravation of arthritis may be presumed to have been incurred or aggravated if the disability is manifested to a compensable degree within one year of the Veteran’s discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established for a chronic disability manifested by certain signs or symptoms which 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, 2021, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1); 81 FR No. 200, pp. 71382-71384 (October 17, 2016). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Functional gastrointestinal disorders; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a). 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). “Objective indications of 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. 38 C.F.R. § 3.317(a). Disabilities that have existed for 6 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. 38 C.F.R. § 3.317(a). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue (2) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran’s most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran’s own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term “Persian Gulf Veteran” means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 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). In this case, service personnel records reflect that the Veteran arrived in Southwest Asia in December 1990 and departed in May 1991. Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. 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 caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b). Entitlement to service connection for a respiratory disability Service treatment records reflect that in January 1982, the Veteran denied chronic cough, chronic or frequent colds, sinusitis, hay fever, asthma, and shortness of breath. On periodic examination in January 1986, the Veteran’s lungs and chest were normal. In December 1986, he was treated for an upper respiratory infection. In March 1992, the Veteran denied chronic or frequent colds, sinusitis, hay fever, asthma, and shortness of breath. Examination revealed normal nose, mouth and throat, and lungs and chest. In January 1996, the Veteran was treated for pneumonia. He was treated in December 1996 for an upper respiratory infection. In February 1997, the Veteran denied chronic or frequent colds, sinusitis, hay fever, asthma, and shortness of breath. On examination, his nose, mouth and throat, and lungs and chest were normal. On retirement examination in May 1999, the Veteran’s lungs and chest were normal. A chest X-ray was normal. At that time, the Veteran denied shortness of breath, chest pain, and chronic cough. He was deemed qualified for retirement. A private medical record dated in July 2015 from T.V., MD notes that the Veteran denied chest pain, shortness of breath, and dizziness. Examination revealed clear lungs. On VA examination in August 2015, the examiner concluded that there was no diagnosis of a respiratory condition. She noted the Veteran’s description of a heartburn type feeling in the center of his chest, as well as shortness of breath, and his statement that he easily had sore throats. He reported that he was exposed to burn pits in Southwest Asia. On chest X-ray, the lungs and pleural spaces were normal. Pulmonary function tests were also normal. The examiner acknowledged that the Veteran had been treated for flu-like symptoms in 1995, and for pneumonia in 1996. She pointed out that service treatment records were otherwise negative, and that current diagnostic testing was also negative. The question for the Board is whether the Veteran has a current respiratory disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. As noted in the recitation of the evidence, there is no diagnosis of a respiratory disability. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). To the extent that the Veteran asserts that he has a respiratory disability, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to report incidents and symptoms; he is not; however, competent to render an opinion as to whether there is a currently existing respiratory disability, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. To qualify for compensation under 38 U.S.C. § 1110, the Veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. Thus, the preponderance of the evidence is against the claim and there is no doubt to be resolved. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for chronic fatigue syndrome (CFS) Service treatment records reflect that on retirement examination in May 1999, the Veteran denied easy fatigability. He was deemed qualified for retirement. In a March 2015 statement, T.V., MD, indicated that the Veteran’s present diagnosis was “Symptoms of Gulf War undiagnosed illness”. He stated that he was board certified to practice in his specialty, but did not identify that specialty. He indicated that he had “personal reviewed his medical history and I have also reviewed his history of the event and undiagnosed Gulf War Illnesses while he served”. He stated that it was his opinion that “the currently existing medical conditions is” related to an injury, disease, or event occurring during service. He specified that irritable bowel syndrome symptoms, fibromyalgia symptoms, and chronic fatigue syndrome symptoms “occurred during service (as described by the Veteran or found in other records provided by the Veteran)”. In an undated statement received by VA in March 2015, the Veteran indicated that over the previous three years, he had experienced a constant feeling of fatigue. He noted that he had enlarged lymph nodes on the right side of his neck, and that he was unable to sleep. He also indicated that he experienced dizziness, visual disturbances, and memory and concentration problems. A July 2015 record from Dr. V. notes that the Veteran denied dizziness, visual disturbances, and confusion. On VA examination in August 2015, the examiner indicated that there was no diagnosis of CFS. The Veteran reported that he was tired all of the time. He denied undergoing care or treatment. He stated that he received a brochure in the mail discussing signs and symptoms related to the Gulf War, and that he felt as if he had similar symptoms. The examiner indicated that the Veteran did not have a clinical diagnosis of CFS, and that it was less likely than not that his tiredness and fatigue were related to an illness or injury during service, to include Southwest Asia. She pointed out that the Veteran had been employed as a Junior Reserve Officer Training Corps instructor for 16 years, and that he worked a full-time schedule. She also noted that he enjoyed working out and that his only limitation concerned increasing joint pain and discomfort. The question for the Board is whether the Veteran has a diagnosis of CFS that began during service or is at least as likely as not related to an in-service injury, event, or disease. Having carefully reviewed the record, the Board concludes that service connection for CFS is not warranted. In that regard, the Board observes that the August 2015 VA examiner determined that a diagnosis of CFS was not applicable. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer; see also Gilpin (service connection may not be granted unless a current disability exists). The Board acknowledges that Dr. V. indicated a diagnosis of “Symptoms of Gulf War undiagnosed illness”. However, he provided no discussion of how the Veteran’s symptoms fit a clinical diagnosis of CFS. Rather, he simply indicated that the Veteran had CFS symptoms. On the other hand, the VA examiner reviewed the record, conducted an interview, and examined the Veteran. She ultimately concluded that the Veteran did not have a clinical diagnosis of CFS. There is no indication that the VA examiner was not fully aware of the Veteran’s history or that she misstated any relevant fact. The Board thus finds the VA examiner’s opinion to be of greater probative value than the Dr. V.’s conclusory statements. To the extent that the Veteran asserts that he has CFS, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms; he is not; however, competent to render an opinion as to whether he has a diagnosis of CFS, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. To qualify for compensation under 38 U.S.C. § 1110, the Veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. Thus, the preponderance of the evidence is against the claim and there is no doubt to be resolved. Entitlement to service connection for irritable bowel syndrome (IBS) Service treatment records reflect that in January 1982, the Veteran denied frequent indigestion and stomach or intestinal trouble. He also denied piles or rectal disease. In December 1985, the Veteran was assessed with gastroenteritis. On periodic examination in January 1986, the Veteran’s abdomen, anus, and rectum were normal. In March 1992, the Veteran denied frequent indigestion and stomach or intestinal trouble. On examination, his abdomen and viscera were normal, as were his anus and rectum. In February 1997, the Veteran denied frequent indigestion and stomach or intestinal trouble. The abdomen and viscera were normal. The anus and rectum were not examined. On retirement examination in May 1999, the Veteran denied frequent indigestion and stomach or intestinal trouble. Clinical examination revealed normal abdomen and viscera, as well as anus and rectum. The Veteran was deemed qualified for retirement. In July 2013, colonoscopy at a private facility was negative except for a sessile polyp in the sigmoid colon. Pathology was also negative. In a March 2015 statement, T.V., MD, indicated that the Veteran’s present diagnosis was “Symptoms of Gulf War undiagnosed illness”. He stated that he was board certified to practice in his specialty, but did not identify that specialty. He indicated that he had “personally reviewed his medical history and I have also reviewed his history of the event and undiagnosed Gulf War Illnesses while he served”. He stated that it was his opinion that “the currently existing medical conditions is” related to an injury, disease, or event occurring during service. He specified that irritable bowel syndrome symptoms, fibromyalgia symptoms, and chronic fatigue syndrome symptoms “occurred during service (as described by the Veteran or found in other records provided by the Veteran)”. In an undated statement received by VA in March 2015, the Veteran indicated that he had experienced changes in his bowel habits and pain in his low belly for the previous three years. He noted that this caused anxiety and depression. In an undated statement received by VA in March 2015, the Veteran’s wife indicated that she had known him since June 2008. She noted that the Veteran experienced severe cramps in his lower abdomen, and that over the counter medication did not help. In an undated statement received by VA in March 2015, the Veteran’s wife indicated that she had known him since June 2008. A July 2015 record from Dr. V. notes that the Veteran denied weight loss or gain, nausea, and vomiting. Examination revealed normal bowel sounds, with no guarding or rebound. On VA examination in August 2015, the examiner noted that the Veteran did not have any stomach or duodenum condition. The Veteran reported that he initially experienced bloating, stomach pain, and cramps in 2014. He indicated that he was seen by his primary care provider but did not require additional treatment or follow up. The examiner remarked that the Veteran was treated for gastritis in 1985 and instructed to return as needed. He noted that the service treatment records were otherwise silent. He stated that no diagnosis was rendered. On VA intestinal conditions examination in August 2015, the Veteran reported onset of symptoms such as cramping, diarrhea, and constipation in 2013. He indicated that he had diarrhea on average once weekly, and constipation every two weeks. He related that his primary care provider had instructed him regarding diet and exercise, but that he had not required additional care or treatment. The examiner concluded that the Veteran did not meet the clinical criteria for a diagnosis of IBS, and that a diagnosis was not rendered. The question for the Board is whether the Veteran has a diagnosis of IBS that began during service or is at least as likely as not related to an in-service injury, event, or disease. Having carefully reviewed the record, the Board concludes that service connection for IBS is not warranted. In that regard, the Board observes that the August 2015 VA examiner determined that a diagnosis of IBS was not applicable. In the absence of proof of a current disability, there can be no valid claim for service connection. The Board acknowledges that Dr. V. indicated a diagnosis of “Symptoms of Gulf War undiagnosed illness”. However, he provided no discussion of how the Veteran’s symptoms fit a clinical diagnosis of IBS. Rather, he simply indicated that the Veteran had IBS symptoms. On the other hand, the VA examiner reviewed the record, conducted an interview, and examined the Veteran. She ultimately concluded that the Veteran’s symptoms did not meet the criteria for a clinical diagnosis of IBS. There is no indication that the VA examiner was not fully aware of the Veteran’s history or that she misstated any relevant fact. The Board thus finds the VA examiner’s opinion to be of greater probative value than the Dr. V.’s conclusory statements. To the extent that the Veteran asserts that he has IBS, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms; he is not; however, competent to render an opinion as to whether he has a diagnosis of IBS, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. To qualify for compensation under 38 U.S.C. § 1110, the Veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. Thus, the preponderance of the evidence is against the claim and there is no doubt to be resolved. Entitlement to service connection for arthritis of the back, knees, legs, and right ankle As an initial matter, the Board observes that the Veteran is in receipt of VA disability compensation for a left ankle disability, which resulted from a tarsal chip fracture. That issue will not be addressed herein. Service treatment records reflect that in January 1982, the Veteran endorsed recurrent back pain. The examiner did not record any specific information with respect to this complaint. On periodic examination in January 1986, the Veteran’s back and lower extremities were normal. In March 1992, the Veteran denied recurrent back pain; arthritis, rheumatism, or bursitis; bone, joint or other deformity; and lameness. On examination, his spine, feet, and lower extremities were normal. In July 1993, the Veteran was assessed with a Grade I left knee sprain. It was subsequently noted to be resolving. In February 1997, the Veteran endorsed recurrent back pain. He denied arthritis, rheumatism, or bursitis; bone, joint or other deformity; and lameness. On examination, his spine, feet, and lower extremities were normal. An undated report of acute medical care indicates an assessment of mid thoracic and low back pain. Diagnostic tests were all within normal limits. On retirement examination in May 1999, the Veteran denied arthritis, rheumatism, or bursitis. He did not respond to the item inquiring about trick or locked knee. He denied foot trouble and recurrent back pain or injury. He endorsed bone, joint, or other deformity, specifying knee and ankle sprain. On clinical examination, the examiner indicated degenerative joint disease of the left ankle and knee. The Veteran was deemed qualified for retirement. In an undated statement received by VA in March 2015, the Veteran’s wife indicated that she had known him since June 2008. She noted that the Veteran experienced problems with his knees and legs, and that he had difficulty after arising after prolonged sitting. The question for the Board is whether the Veteran has arthritis of the back, knees, legs, and right ankle that began during service; is at least as likely as not related to an in-service injury, event, or disease; or is related to a service-connected disability. In this regard, the Board observes that although the Veteran has been advised of the evidence necessary to support his claim, he has neither identified nor produced evidence showing arthritis of the back, knees, legs, or right ankle. In the absence of proof of a current disability, there can be no valid claim for service connection. The Board acknowledges the Veteran’s contention regarding the existence of a back, knee, leg, and right ankle disability; however, there is no competent evidence diagnosing such. The Board also acknowledges that pain can cause disability to the extent that it produces functional limitation. Saunders v. Wilkie, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018). However, the relevant statute here, 38 U.S.C. § 1110, requires that for the grant of service connection the disability must be due to an identified disease or residual of injury. This principle has been repeatedly reaffirmed by the Federal Circuit, which has stated that “a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran’s service and the disability.” Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Here, there is no evidence demonstrating functional limitation of the back, knees, legs, or right ankle due to pain, and no objective evidence of an in-service disease or injury. To the extent that the Veteran asserts that he has arthritis of the back, knees, legs, and right ankle, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to report incidents and symptoms; he is not; however, competent to render an opinion as to whether there is current arthritis, because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. To qualify for compensation under 38 U.S.C. § 1110, the Veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. Thus, the preponderance of the evidence is against the claim and there is no doubt to be resolved. Entitlement to service connection for PTSD The requirements for establishing service connection for PTSD are more specific than those for establishing service connection for other psychiatric disabilities. To establish service connection for PTSD, the evidence must satisfy three basic elements: 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). 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 U.S.C. § 1154(b) and 38 C.F.R. § 3.304(d), (f). Additionally, 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. 38 C.F.R. § 3.304 (f)(3); see 75 Fed. Reg. 39843 (July 13, 2010). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (permanently worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Service treatment records indicate that in January 1982, the Veteran denied frequent trouble sleeping, depression or excessive worry, memory loss, and nervous trouble of any sort. On periodic examination in January 1986, the Veteran was psychiatrically normal. In March 1992, the Veteran denied frequent trouble sleeping, depression or excessive worry, memory loss, and nervous trouble of any sort. On examination, he was psychiatrically normal and deemed qualified for drill instructor school. In February 1997, the Veteran denied frequent trouble sleeping, depression or excessive worry, and memory loss. He indicated that he did not know if he had nervous trouble of any sort. On examination, he was psychiatrically normal. On retirement examination in May 1999, the Veteran was psychiatrically normal. He denied frequent trouble sleeping, memory loss, and nervous trouble. In a March 2015 statement, the Veteran’s private physician indicated that the Veteran’s present diagnosis was PTSD. He stated that he was board certified to practice in his specialty, but did not identify that specialty. He indicated that he had “personal reviewed his medical history and I have also reviewed his history of the event and undiagnosed Gulf War Illnesses while he served”. He stated that it was his opinion that “the currently existing medical conditions is” related to an injury, disease, or event occurring during service. In an undated statement received by VA in March 2015, the Veteran’s wife indicated that she had known him since June 2008. She noted that the Veteran was sometimes very forgetful, and that he had difficulty sleeping. A private medical record dated in July 2015 indicates that the Veteran was seen for PTSD. He requested medication. In September 2015, the AOJ concluded that the information provided by the Veteran to corroborate his reported stressors was insufficient to send to the service department or insufficient to allow for meaningful search of service-department records. On VA examination in September 2015, the examiner concluded that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD. She provided a diagnosis of alcohol use disorder. She recited the Veteran’s history, as well as his reported symptoms, but ultimately determined that his symptoms did not support a diagnosis of PTSD. The Veteran reported that he was employed with the public school system and that he had not been involved in any incident or been subjected to disciplinary action. The Veteran’s wife reported her belief that his behavior was affected by alcohol consumption, and stated that his alcohol consumption was “too much”, although she did not quantify it. The Veteran endorsed drinking daily, but was evasive regarding how much. The examiner concluded that the results of the examination suggested that the Veteran’s primary clinical and behavioral issues were most directly borne out of his excessive alcohol consumption, consistent with an alcohol use disorder. Specifically, she noted his report of experiencing "emotional outbursts," and poor sleep, as well as some preference to isolate and consume alcohol. She indicated that chronic alcohol use, including alcohol intoxication and withdrawal, could create physiological changes to the brain that adversely affect the regulation of mood and behavior. She stated that due to the acuity of the Veteran’s untreated alcohol use disorder, she could not diagnose other mental health disorders at that time. She noted that, significantly, the Veteran was functioning well at work and home. She pointed out that the Veteran appeared to be taking good care of his hygiene and grooming, that he could keep up with demands at work, was able to participate in family and social activities without a problem, and that he reported being a "social person." She indicated that conflicts appeared to arise primarily when the Veteran was intoxicated and became easily irritable. She indicated that he was future oriented, and in no acute distress. She recommended that the Veteran seek substance abuse treatment. After careful consideration of the evidence, the Board finds that service connection for PTSD is not warranted. In this regard, the Board notes that a key element to establishing service connection is to show that Veteran has the claimed disability that meets the diagnostic criteria in accordance with the controlling VA regulation. This element may only be shown through evidence of a diagnosis of PTSD. The Board acknowledges that Dr. V. indicated a diagnosis of PTSD. However, while he indicated a diagnosis of PTSD, he did not provide a specific discussion of how the Veteran’s symptoms and presentation met the criteria for the diagnosis. On the other hand, VA examiners conducted a detailed clinical interview and reviewed the record in reaching her conclusion that a diagnosis of PTSD was not appropriate. This examiner carefully explained why the Veteran’s reported symptoms and clinical presentation did not comport with a diagnosis of PTSD. In assigning high probative value to the VA examiner’s opinion, the Board notes that she had the claims file for review, specifically discussed evidence contained in the claims file, obtained a history from the Veteran, conducted a complete examination which included a focused clinical interview, and offered detailed rationale with discussion of the Veteran’s history and the findings of the examination in application to her conclusions. There is no indication that this VA examiner was not fully aware of the Veteran’s history or that she misstated any relevant fact. The Board thus finds the VA examiner’s opinion to be of greater probative value than the Veteran’s unsupported statements. To the extent that the Veteran claims that he has PTSD, the Board observes that while he is competent to describe symptoms and when they occurred, he is not competent as a lay person to ascribe a diagnosis to those symptoms. Thus, in determining whether he has PTSD, the Board places far more probative weight on the clinical findings of the VA examiner who conducted full and comprehensive assessments prior to rendering her conclusions. Under these circumstances, the Board must conclude that the Veteran has not met the regulatory requirements of entitlement to service connection for PTSD. As such, the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for PTSD and that the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Effective date for addition of the Veteran’s spouse On January 11, 2015, the Veteran submitted VA Form 21-686c, Declaration of Status of Dependents, indicating that he had married his spouse on December 23, 2009. On that date, a letter was issued notifying him that his wife had been added to his award effective February 1, 2015. In March 2015, the Veteran indicated that he disagreed with the effective date of the addition of his wife to his award. He stated that the effective date should be the date they were married. The effective date for the award of additional compensation for dependents will be the latest of the following dates: (1) date of claim; (2) date the dependency arises; (3) effective date of the qualifying disability rating provided evidence of dependency is received within a year of notification of such rating action; or (4) date of commencement of the Veteran’s award. 38 C.F.R. § 3.401(b). The “date of claim” for additional compensation for dependents is either (1) the date of the Veteran’s marriage or birth/adoption of a child, if evidence of the event is received within a year of the event; or (2) the date notice is received of the dependent’s existence, if evidence is received within a year of notification of VA’s request. 38 C.F.R. § 3.401(b)(1). The earliest that the additional award of compensation for a dependent can occur is the first day of the month following the effective date. 38 C.F.R. § 3.31 Upon review of the record, the Board concludes that an effective date prior to February 1, 2015 for payment of additional compensation for the Veteran’s spouse is not warranted. In this regard, there is no notification from the Veteran prior to his January 2015 submission indicating that he had a dependent spouse. Therefore, based on the law, the appropriate effective date for the addition of the Veteran’s spouse to his award is February 1, 2015. There is no reasonable doubt to be resolved; therefore, the claim must be denied. REASONS FOR REMAND Entitlement to service connection for obstructive sleep apnea Service treatment records indicate that in January 1982, the Veteran denied asthma and shortness of breath. He also denied frequent trouble sleeping. On periodic examination in January 1986, the Veteran’s nose, mouth, and throat were normal. In March 1992, the Veteran denied asthma and shortness of breath, as well as frequent trouble sleeping. His nose, sinuses, mouth and throat, and lungs and chest were normal. In February 1997, the Veteran denied asthma and shortness of breath. He also denied frequent trouble sleeping. His nose, sinuses, mouth and throat, and lungs and chest were normal. On retirement examination in May 1999, the Veteran’s nose, mouth, throat, lungs, and chest were normal. He denied frequent trouble sleeping. He was deemed qualified for retirement. In an undated statement received by VA in March 2015, the Veteran’s wife indicated that she had known him since June 2008. She noted that the Veteran had difficulty sleeping through the night, and awoke regularly. A private medical record dated in July 2015 from T.V., MD notes an assessment of insomnia. On VA examination in August 2015, the examiner indicated that the Veteran did not have a diagnosis of sleep apnea. The Veteran reported that he felt tired all of the time, and that he awoke without feeling refreshed since 2013. He denied requiring additional follow up or treatment. The examiner noted that the Veteran took a prescription sleep aid. She noted that the Veteran claimed a disability pattern related to sleep apnea due to environmental exposure experienced in the Gulf War. She indicated that the Veteran’s disability pattern, obstructive sleep apnea, was a disease with a clear and specific etiology and diagnosis. She noted that obstructive sleep apnea was due to obstruction of the airway during sleep. She pointed out that there were several risk factors, to include obesity, narrow airway, and genetic predisposition. She concluded that it was less likely as not that the Veteran’s sleep apnea was related to a specific exposure during service in Southwest Asia. This statement conflicts with the examiner’s earlier statement that there was no diagnosis of sleep apnea. Moreover, the examiner did not provide a discussion of the medical basis for her conclusion. The Board additionally notes that the September 2015 report of sleep polysomnography at a VA facility indicates an assessment of sleep apnea. As there is a diagnosis of sleep apnea, the VA examiner should be asked to clarify her opinion, and provide a discussion of the medical basis for her conclusions. Entitlement to service connection for alcohol use disorder The law states that service connection cannot be established on a direct basis for a disease or injury that results from a claimant’s abuse of alcohol or drugs, as such abuse constitutes willful misconduct. 38 C.F.R. §§ 3.1(m), 3.301(a). However, while direct service connection for the diagnosed alcohol use disorder is precluded as a matter of law, it is possible for service connection for an alcohol use disorder to be awarded on a secondary basis, if the alcohol use disorder was caused or aggravated by another service connected disability. 38 C.F.R. § 3.310; VAOPGCPREC 2-98 (Feb. 10, 1998). Because there is a diagnosis of alcohol use disorder, and the Veteran is in receipt of VA disability compensation, the Board concludes that an examination should be conducted to determine whether alcohol use disorder is secondary to a service-connected disability. The matters are REMANDED for the following action: 1. Request that the August 2015 VA examiner again review the claims file and provide clarification as to the etiology of the Veteran’s sleep apnea. If the August 2015 VA examiner is unavailable, the record should be reviewed by a similarly qualified clinician who should be asked to provide the requested opinion. If it is determined that an additional examination of the Veteran is required, such should be scheduled. Following review of the claims file and examination of the Veteran if deemed necessary, the clinician should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that sleep apnea is related to service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. In discussing the rationale for his opinion, the examiner should address the private medical reports of record indicating pathology of the knees. If the examiner is unable to offer any of the requested opinions, a rationale for the conclusion that an opinion cannot be provided without resort to speculation should be provided, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Schedule the Veteran for a VA examination to determine the etiology of his alcohol use disorder. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Following review of the record and examination, the examiner should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that alcohol use disorder was caused or aggravated by any service-connected disability. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. In discussing the rationale for his opinion, the examiner should address the private medical reports of record indicating pathology of the knees. (Continued on the next page)   If the examiner is unable to offer any of the requested opinions, a rationale for the conclusion that an opinion cannot be provided without resort to speculation should be provided, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Barone, Counsel