Citation Nr: 18155614 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 98-07 445 DATE: December 4, 2018 ORDER Service connection for chronic mouth ulcers, to include pemphigus, and to include as due to an undiagnosed illness, is granted. Service connection for a circulatory disorder, to include peripheral vascular disease, and to include as due to an undiagnosed illness, is denied. Service connection for an acquired psychiatric disorder, to include a depressive disorder, and to include as due to an undiagnosed illness, is denied. FINDINGS OF FACT 1. The Veteran served in the Southwest Asian Theater during the Persian Gulf War. 2. The Veteran’s chronic mouth ulcers have been attributed to pemphigus that is causally or etiologically related to service. 3. The Veteran’s circulatory disorder has been attributed to a known clinical diagnosis, and is not shown to be causally or etiologically related to service. 4. The Veteran’s acquired psychiatric disorder has been attributed to a known clinical diagnosis, and is not shown to be causally or etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for chronic mouth ulcers, to include pemphigus, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 2. The criteria for entitlement to service connection for a circulatory disorder, to include peripheral vascular disease, to include as due to an undiagnosed illness, are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 3. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include a depressive disorder, to include as due to an undiagnosed illness, are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1974 to May 1975, and from January 1991 to October 1991, including service in the Southwest Asia Theater during the Persian Gulf War, with additional service in the Reserves. Considering the span of time over which the claims have been in appellate status, and the procedural lineage that culminates in the instant adjudication, a review of the procedural background of this case is in order. In November 2003, the Board remanded the above-referenced claims, as well as a claim for an increased rating for a low back disability for further development. In December 2008, the Board denied service connection claims for mouth ulcers, circulatory disorder, psychiatric disorder, nasal allergic disorder, throat disorder, dehydration, headaches, stomach disorder, and seizures. The Board also granted an initial disability rating of 40 percent for the Veteran’s low back disability from May 31, 2007; denied an initial rating in excess of 20 percent for the period prior to May 31, 2007; and denied an initial rating in excess of 30 percent since July 4, 2001 for folliculitis of the chest, back, and forearms. The Board remanded the issues of entitlement to an initial rating in excess of 10 percent prior to July 4, 2001 for a skin disability; entitlement to an effective date earlier than July 4, 2001, for a 30 percent disability evaluation for the Veteran’s skin disability; and entitlement to a total rating based on individual unemployability (TDIU). The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a joint motion for remand in March 2010 (JMR), which was granted by the Court, the Veteran’s claims for an increased rating for his low back disability, for an earlier effective date and increased rating for service-connected folliculitis, his claim for a TDIU, and claims for service connection for an acquired psychiatric disorder, chronic mouth ulcers, circulatory, throat, and headaches disorders were remanded by the Court to the Board. The JMR specified that in regard to the Veteran’s claim for service connection for a psychiatric disorder, prior VA examinations are inadequate. Additionally, treatment records in Spanish were to be translated to English. The Board notes that translated records have been associated with the claims file and reviewed. In a March 2011 decision, the Board denied an initial evaluation in excess of 20 percent for the Veteran’s low back disability, and remanded the service connection claims for mouth ulcers, circulatory disorder, psychiatric disorder, throat disorder, and headaches for examinations and medical opinions. In September 2014, the Board granted an initial 50 percent evaluation for folliculitis of the chest, back, and forearms for the period from November 3, 1993 to July 3, 2001, and directed that new VA examinations be provided for the mouth ulcers, circulatory disorder, psychiatric disorder claims. In rating decisions dated November 2016 and June 2017, the RO granted an earlier effective date and increased ratings for folliculitis, and service connection for obstructive sleep apnea (formerly claimed as a throat disorder), headaches disorder, and TDIU. Given that the November 2016 and June 2017 decisions are full grants of the benefits sought by the Veteran, these claims are no longer before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). Additionally, in May 2018, the Board requested an opinion from the Veterans Health Administration (VHA) to further clarify the issue of the claim for service connection for a psychiatric disorder. The request was answered satisfactorily in a July 2018 VHA medical opinion. The record reflects that in August 2018 the Veteran was provided a copy of the VHA opinion along with notice that he had 60 days from the date of the letter (August 14, 2018) to submit additional evidence or argument in support of his claim pursuant to 38 C.F.R. § 20.903. On August 31, 2018, the Veteran submitted notice to the Board that he had no further argument or evidence to submit, and requested that the Board proceed with adjudication of his claims. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). “Active military, naval, or air service” includes active duty; any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; or any period of inactive duty for training (INACDUTRA) in which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. See 38 U.S.C. § 101(24); 38 C.F.R. § 3.6; see also Biggins v. Derwinski, 1 Vet. Ap. 474, 478 (1991). An alternative means of establishing service connection is showing continuity of symptomatology under 38 C.F.R. § 3.303(b); however, this alternative means is only available for certain “chronic disease” specifically enumerated under 38 C.F.R. § 3.309(a), and the record here does not reflect that the disorders that gave rise to this appeal are among the listed diseases. Therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As relevant to the discussion below, personality disorders are not diseases or injuries under VA regulations and, therefore, are not disabilities for which service connection can be granted. 38 C.F.R. § 3.303(c). Nevertheless, service connection may be granted if the evidence shows that an acquired psychiatric disorder was incurred or aggravated in service and superimposed upon the preexisting personality disorder. 38 C.F.R. §§ 4.9, 4.125(a), 4.127. If a veteran who served in Southwest Asia during the Persian Gulf War has a cluster of objective symptoms, but no specific diagnosis, or if there is a specific diagnosis with no identified medical cause, service connection may be presumed for the undiagnosed illness or the diagnosed medically unexplained multi-symptom illness. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; Gutierrez v. Principi, 19 Vet. App. 1 (2004). As discussed below, however, the Veteran’s diagnoses have specifically been attributed to known clinical diagnoses, namely, pemphigus, bilateral peripheral vascular disease, and a depressive disorder. Therefore, the presumption pertaining to an undiagnosed illness is not warranted for the instant claims. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Service connection for chronic mouth ulcers, to include pemphigus, and to include as due to an undiagnosed illness. The Veteran asserts that his chronic mouth ulcers, diagnosed as pemphigus, are related to service, including his service in the Persian Gulf. See Statement in Support of Claim dated March 17, 1997; VA examination dated August 15, 2000 at pg. 1. At the outset, the Board finds that credible medical evidence establishes a diagnosis of pemphigus during the period on appeal. See e.g. VA neurology examination dated November 2, 2012 at pg. 2; see also JMR at pg. 2. The Veteran’s service treatment records (STRs) do not reflect complaints or diagnosis of mouth ulcers. However, the Veteran’s post-service VA treatment records include diagnoses of pemphigus, which is at times asymptomatic in regard to visible ulcers. See Progress Notes entry dated August 3, 1993 and March 2, 1994. VA outpatient treatment records reflect complaints of lesions of the mouth and throat. See e.g. VA general medical examination dated December 11, 1995 (acantholysis of mouth mucosa); VA treatment record dated January 21, 1998 and February 17, 1999. VA examinations dated December 1995, August 2000, August 2005, and November 2012 reflect diagnoses of pemphigus vulgaris; however, none of the examination reports include medical opinions as to its etiology. Of note, during the November 2012 examination, the Veteran reported that his mouth ulcerations were successfully treated with prednisone in the early 1990s, but that he continued to experience burning sensations in his mouth caused by acidic food and drink. Pursuant to the Board’s September 2014 remand, the Veteran was afforded new examination in March 2016. The VA examiner confirmed the diagnosed of pemphigus, and opined that the Veteran’s pemphigus is at least as likely as not related to service. The examiner explained that mouth ulcers are a clinical oral manifestation of pemphigus due to the mucosal composition of the oral cavity. Among the service medical evidence discussed was the March 1994 diagnosis of pemphigus. The Board finds the March 2016 VA medical opinion on the matter of a nexus to be competent, credible, and highly probative. The opinion is factually accurate, the conclusions are supported with reasoned analysis, and the author has demonstrated that he is competent through education, training, and experience to offer the medical opinion. Therefore, the March 2016 VA medical opinion is accorded considerable probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The RO acknowledged the March 2016 medical opinion, but denied service connection on the basis that the disorder was diagnosed during a period of ACDUTRA. See Supplemental Statement of the Case dated June 7, 2017 at pg. 10. While objective medical evidence reflects that the Veteran was diagnosed with pemphigus in March 1994, it does not reveal the initial onset of the ulcers. The symptoms of pemphigus, an autoimmune disorder, wax and wane. Dorland’s Illustrated Medical Dictionary, 1425 (31st ed. 2007). This is consistent with objective notations in the Veteran’s treatment records, which reflect that the Veteran has had visible mouth ulcers at times, and at other times does not. Notably, the Veteran has indicated that symptoms of pemphigus onset during his active duty service in 1991 during the Gulf War. See, e.g. Appeal to Board of Veteran’s Appeals dated April 3, 1998; Statement in Support of Claim dated February 10, 2002. The Veteran, as a layperson, is competent to report on the onset and continuity of symptomatology. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Moreover, the Board does not doubt the credibility of his lay statements. Accordingly, the Board finds that the preponderance of the evidence establishes that the Veteran currently has pemphigus that is etiologically related to active duty service, and that service connection for pemphigus is warranted. 2. Service connection for a circulatory disorder, to include peripheral vascular disease, and to include as due to an undiagnosed illness. The Veteran asserts that his circulation problems are related to service, including his service in the Persian Gulf. See e.g. Notice of Disagreement dated March 17, 1997. As an initial matter, the Board finds that credible medical evidence establishes a diagnosis of bilateral peripheral vascular disease during the period on appeal. See VA examination report dated March 22, 2016 at pg. 1; see also JMR at pg. 2. The Veteran’s STRs are silent for complaints or diagnoses of circulatory problems. Post-service VA treatment records indicate that the Veteran was examined in March 1994, at which time a venogram showed no evidence of venous disease. See VA medical record/nursing documentation dated March 5, 1994. He was seen for bilateral leg edema in May 2000, and he was diagnosed with peripheral vascular disease in August 2005. See VA treatment record dated September 6, 2006. During a December 1995 VA general medical examination, the examiner noted normal peripheral circulation, and normal arteries and veins, with normal pulsation. The Veteran was given a VA examination in June 2007, at which time he reported that his legs began swelling while he was serving in the Persian Gulf, and that his legs continued to swell with prolonged standing or walking, which resolved on its own. The examiner noted that there was no evidence of a circulatory disorder during the VA examination. The examination report includes no medical opinion. The Veteran underwent a VA examination in November 2012. The diagnosis was bilateral lower extremities peripherovascular disease confirmed by arterial Doppler scan, which showed arterial wall calcification mostly involving the runoff vessels and mild stenotic disease of the left anterior tibialis with decreased flow. There were no hemodynamically significant stenoses or occlusions. Due to extensive calcification of the blood vessels, the Veteran was unable to perform ankle/brachial index testing, bilaterally. The examiner characterized it as a peripheral vascular disease, aneurysm of any large artery (other than aorta), arteriosclerosis obliterans or thrombo-angiitis obliterans (Buerger’s Disease). It was noted that the Veteran experienced claudication bilaterally walking between 25 and 100 yards on a level grade at two miles per hour. The examiner opined that the Veteran’s bilateral vascular disease was less likely than not related to service, explaining that there is no evidence of circulatory problems or edema during service, and the first evidence of bilateral peripherovascular disease was in 2005, 14 years after the Veteran’s discharge from active duty service. Pursuant to the Board’s September 2014 remand, the Veteran was afforded new VA examination in March 2016. The examiner diagnosed bilateral lower extremities peripherovascular disease. See March 2016 VA examination report at pg. 1. During the examination, the Veteran endorsed bilateral foot pain and edema in both ankles. He reported having had an ulcer in 2015, which resolved with treatment using topical creams and aloe. The Veteran endorsed regular use of a cane to avoid falls when having pain in left knee and/or lower back. He denied having surgery for circulatory problems. The examiner noted that ultrasound scans of the Veteran’s ankles were conducted in December 2012, which revealed arterial wall calcifications mostly involving runoff vessels where biphasic waveform patterns were indicated. No occlusions or clinically significant stenosis was identified in either leg. The imagery suggested mild stenotic disease at the left anterior tibialis with decreased flow. The ankle brachial index (ABI) could not be calculated due to extensive calcification of the blood vessels. The impression was arterial wall calcifications, primarily involving the mild vessels precluding measurements of ABI; and minimal stenotic changes at the left anterior tibialis artery. Otherwise, no hemodynamically significant stenosis or occlusions were identified. The examiner opined that the Veteran’s bilateral lower extremities peripherovascular disease was less likely as not incurred in or caused by the Veteran’s active duty service, to include exposure to environmental hazards during the Veteran’s Persian Gulf service. The examiner explained that bilateral lower extremities peripherovascular disease has a clear and specific etiology and diagnosis, and that the medical literature does not support a direct etiologic relationship between past exposure to dust, fumes, smokes, particulate matter, and further development of the disease. The examiner also noted that the Veteran’s STRs reflect no diagnosis of the disease during service, and there is no evidence of any manifestations or diagnosis of the disease until many years after the Veteran’s separation from service. The Board finds the March 2016 VA medical opinion on the matter of a nexus to be competent, credible, and highly probative. The opinion is factually accurate, the conclusions are supported with reasoned analysis, and the author has demonstrated that he is competent through education, training, and experience to offer the medical opinion. Therefore, the opinion is accorded considerable probative weight. See Nieves-Rodriguez, 22 Vet. App. at 301. The Board finds that the claim for service connection is not warranted. In this regard, the Veteran has not submitted competent evidence of a nexus between his current disability and his military service. While the Veteran is competent to offer testimony on observable symptoms of his circulatory disorder, as a lay person he is not competent to provide evidence as to medical questions, particularly complex medical questions, such as determining the etiology of disorders of the circulatory system. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). As such, the Veteran’s assertions regarding etiology of his peripherovascular disease are afforded no probative weight as he is not shown to possess the medical expertise to render opinions about medical matters. Therefore, the Board finds that the Veteran’s lay statements of record cannot be accepted as competent evidence sufficient to establish service connection for a circulatory disorder. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a circulatory disorder, and 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. 3. Service connection for an acquired psychiatric disorder, to include a depressive disorder, and to include as due to an undiagnosed illness. The Veteran seeks service connection for an acquired psychiatric disorder disability, which he claims had its origin during his second period of active duty service in the Persian Gulf. See e.g. Notice of Disagreement dated March 17, 1997; Undated letter from Veteran (VBMS receipt date 12/13/2007, labeled “Correspondence”). The Veteran is currently diagnosed with unspecified depressive disorder. See VA examination report dated March 22, 2016 at pg. 1. The Veteran’s service treatment records are silent for complaints, treatments, or diagnosis of a psychiatric disorder. However, according to the September 1991 separation examination, which includes a Southwest Asia Demobilization Assessment questionnaire, the Veteran indicated that he had trouble sleeping or controlling his thoughts since arriving in Saudi Arabia due to problems at home. See Chronological Record of Medical Care dated September 20, 1991. Post-service VA treatment records reflect diagnoses or assessments that include depression, depressive disorder, anxiety, mood disorder, personality disorder, intermittent explosive disorder, bipolar disorder, and cocaine abuse/dependence, with symptoms that include depressed mood, anxiety, irritability, poor impulse control, and anhedonia. Although the treatment records show that the Veteran reported symptoms beginning after his return from the Gulf War, the treatment records include no objective opinion as to the etiology of a psychiatric disorder. The Board notes that, after his discharge from active duty service, the Veteran has been afforded no fewer than seven VA mental health disorders examinations as part of the development of this claim. However, as reflected in the March 2010 JMR and September 2014 Board remand, the parties have agreed that VA psychiatric examinations conducted prior to the Court’s granting of the JMR are inadequate. As such, VA examinations pertaining to service connection of a psychiatric disorder that are dated prior to the JMR are not adequate for adjudication purposes and need not be discussed further. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran received a favorable determination from the Social Security Administration (SSA) for disability benefits due to a personality disorder in 1998. The Board notes that SSA determinations are not considered binding on VA, as SSA subscribes to different statutory and regulatory criteria. See Collier v. Derwinski, 1 Vet. App. 413 (1991). As noted above, and as relevant below, VA regulations do not provide for service connection for personality disorders unless the evidence shows that an acquired psychiatric disorder was incurred or aggravated in service and superimposed upon the preexisting personality disorder. 38 C.F.R. §§ 4.9, 4.125(a), 4.127. During a VA examination in November 2012 the Veteran was diagnosed with cocaine dependence in full sustained remission. The Veteran stated that he did not start using illicit drugs until after his discharge from active duty service. Although the examiner opined that the Veteran’s cocaine dependence in remission was less likely than not related to service, the rationale for the opinion consists only of an incomplete sentence. Therefore, the November 2012 VA examination is inadequate. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (examination that provides an etiology opinion without a rationale is inadequate). The Veteran was afforded a new VA examination in March 2016 pursuant to the Board’s September 2014 remand. During the examination, the Veteran complained of depressed mood, anxiety, chronic sleep impairment, and disturbances in mood and motivation. The examiner determined the Veteran’s current diagnosis was unspecified depressive disorder and opined that his currently diagnosed mental disorder is less likely as not related to service. The examiner explained that the Veteran’s STRs are silent for behavioral health complaints, findings or diagnoses, and that the Veteran did not begin psychiatric treatment until 2003, twelve years after service. The examiner further noted the Veteran was diagnosed with other psychiatric disorders in the past, to include bipolar disorder, bipolar disorder by history, substance induced mood disorder, cocaine abuse vs. dependence, and anxiety disorder NOS. The examiner indicated that since the Veteran no longer had “bipolar symptoms,” and that “it was most probable” that his manic symptoms were due to his cocaine abuse/dependence because his bipolar symptoms are no longer present since he stopped using cocaine. The examiner stated that it was very common to have depression symptoms after abstinence from cocaine, secondary to a prolonged use of cocaine. Notably, the examiner further found that the Veteran’s mental disorder is not due to an undiagnosed illness. In May 2018, the Board requested a medical opinion from the Veterans Health Administration (VHA) as to whether the Veteran’s personality disorder clearly and unmistakably preexisted service, and if so, whether the personality disorder was subjected to a superimposed disease or injury during service that results in the current acquired psychiatric disorder. Additionally, the Board requested an opinion as to whether any other diagnosed psychiatric disorders are related to service. See Board letter dated May 15, 2018. In July 2018, a VHA board-certified psychologist reviewed the Veteran’s claims file and opined that the Veteran’s personality disorder did not clearly and unmistakably preexist his military service. The psychologist explained that there is no evidence of behavioral health treatment prior to or during service, and explained that while the record reflects that the Veteran had a very difficult childhood, he was able to complete high school and work with no reported behavioral health issues prior to or during military service, that his abusive behavior and his behavior toward women, which he attributed to his parents, did not appear prominent until later in life. The psychologist noted that the Veteran’s arrest in 1994 for physical aggression toward one of his wife’s friends may have been a marker for the beginning of the Veteran’s behavioral health issues. The psychologist also opined that it is less likely as not that the Veteran’s diagnosed bipolar disorder is related to service, explaining that while the Veteran reported stress and communication problems related to his family at discharge, those problems did not require treatment and no treatment is noted until 1994, a few years after the Veteran’s discharge from service, when bipolar symptoms first appeared, along with his reported history of abuse, which led evaluators to conclude that such behavior is related to various personality disorders. The psychologist observed that medications prescribed for the Veteran through the years are consistent with a bipolar diagnosis. Although the psychologist refrained from offering a diagnosis related to substance abuse, the psychologist observed that the Veteran’s drug abuse appears to have occurred after he began experiencing bipolar issues, and further opined that the drug abuse is less likely than not related to service. Finally, the psychologist opined that the Veteran’s anxiety and depression appear also to be related to his bipolar disorder, as they did not appear until after the onset of behavioral issues related to bipolar disorder. The Board finds the March 2016 VA examination and the July 2018 VHA opinion on the matter of a nexus to be competent, credible, and highly probative, and assigns the opinions a high probative value. The psychologists who issued the reports have the knowledge, experience, and training to render the opinion. Furthermore, their opinions are factually accurate, their conclusions are supported with reasoned analysis, and the authors have demonstrated that they are competent through education, training, and experience to offer the medical opinions. Therefore, the March 2016 VA and July 2018 VHA opinions are accorded considerable probative weight. Nieves-Rodriguez, supra. The Board finds that the claim for service connection is not warranted. In this regard, the Veteran has not submitted competent evidence of a nexus between his current psychiatric disability and his military service. While the Veteran is competent to offer testimony on observable symptoms, as a lay person he is not competent to provide evidence as to medical questions, particularly complex medical questions, such as determining the etiology of psychiatric disorders. See Woehlaert, 21 Vet. App. at 462. As such, the Veteran’s assertions regarding etiology of his acquired psychiatric disorder are afforded no probative weight as he is not shown to possess the medical expertise to render opinions about medical matters. Therefore, the Board finds that the Veteran’s lay statements of record cannot be accepted as competent evidence sufficient to establish service connection for an acquired psychiatric disorder. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for an acquired psychiatric disorder, and 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. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brad Farrell, Associate Counsel