Citation Nr: 19102477 Decision Date: 01/10/19 Archive Date: 01/09/19 DOCKET NO. 17-27 231 DATE: January 10, 2019 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder and posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. FINDING OF FACT The preponderance of the evidence of record does not reflect that the Veteran has a current acquired psychiatric disorder related to his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Navy from May 1985 to October 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2017 and May 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The case was previously before the Board in May 2018 and June 2018. In June 2018, the Board remanded the issues to the AOJ for additional development, including, a VA opinion to determine the etiology of the Veteran’s psychiatric condition and to obtain relevant VA treatment records and private treatment records. 1. Entitlement to service connection for an acquired psychiatric disorder The Veteran seeks service connection for an acquired psychiatric disorder, which he asserts is related to service. The Veteran stated that during service he nearly drowned while taking a swimming test; he was classified as a fourth-class swimmer as a result; and a fellow servicemember called him a derogatory term at the time. The Veteran stated that he began drinking heavily after the incident in service and continued to drink heavily and began to abuse drugs after service, in order to self-medicate the symptoms of PTSD and other mental health issues. The Veteran stated that his symptoms included memory loss, depression, suspiciousness, trouble sleeping, panic attacks, suicidal ideation, and anxiousness. He also stated that he was prescribed Prozac and other antidepressants; however, he stopped taking them because of the side effects. He stated that he could no longer go in deep water, and had panicked one day while attempting to go snorkeling. In May 2017, the Veteran’s former spouse stated that the Veteran suffered a panic attack in the water when he attempted to go on a snorkeling tour with her in the ocean. She stated that he had to be pulled back to the boat by the instructors who also helped him climb back into the boat. She stated that the Veteran remained depressed for the remainder of the trip due to this experience. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may also 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 medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), i.e., a diagnosis which conforms to the criteria set forth in the Diagnostic and Statistical Manual of the American Psychiatric Association, 5th edition (DSM-V); a link, established by medical evidence, between the current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the Veteran’s military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a); 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the Veteran “engaged in combat with the enemy.” Id. If VA determines that the Veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the Veteran’s lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f). No further development or corroborative evidence is required, provided that the claimed stressor is “consistent with the circumstances, conditions, or hardships of the Veteran’s service.” Id. If, however, VA determines that the Veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the Veteran’s lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the Veteran’s testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). 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. “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). If a Veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, and the stressor is not related to “fear of hostile military or terrorist activity,” then the Veteran’s testimony alone is not sufficient to establish the occurrence of the claimed stressors and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau, supra; Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Furthermore, service department records must support, and not contradict, the claimant’s testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283, 289 (1994). The question of whether a Veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff’d on recon., 1 Vet. App. 406, 407 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of PTSD is a question of fact for medical professionals and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for an acquired psychiatric disorder, to include depressive disorder and PTSD have not been met. At the outset the Board notes that there is insufficient evidence to corroborate the Veteran’s claim that he nearly drowned in service and feared for his life. The Board notes that the Veteran does not assert, and the evidence does not demonstrate that the Veteran engaged in combat. As such, the Veteran’s testimony alone is not sufficient to establish the occurrence of the claimed PTSD stressor and his testimony must be corroborated by credible supporting evidence. Cohen, supra, Moreau, supra, Dizoglio, supra. Service treatment records are silent as to any complaints or treatment of any water related or swimming related injury in service. Service treatment records are also silent as to any complaints, treatment or clinical diagnosis for a psychiatric disorder. As noted, the Veteran served in the United States Navy from May 1985 to October 1985. The Veteran did not receive any badges or medal that can be conceded as a stressor for PTSD. The Veteran’s DD-214 reflects that the Veteran was discharged from service due to a physical disability, which existed prior to entry on active duty, established by the Medical Board. A September 1985 Medical Board Report reflects a diagnosis of syncope and presyncope associated with previous head trauma, which existed prior to service, but was not aggravated by service. The Veteran reported frequent episodes of nearly losing consciousness and occasionally losing consciousness over the past four years. He also complained of decreased attention span and trouble concentrating, which had been present over the past four years since his trauma. He denied headaches, visual problems or easy irritability. A September 1985 service treatment record reflects that the Veteran admitted to recurrent dizzy spells, presyncope and syncope episodes, and recurrent transient episodes of memory loss prior to service. Further, the Board notes that in relation to the Veteran’s pre-existing syncope and presyncope, the Veteran underwent a series of evaluations, and the treatment provider even noted that the Veteran denied having easy irritability, and there was no indication that the Veteran had any other neurological or psychological problems. Because nearly drowning during a swimming test, would have been relevant to the course of his medical treatment for recurrent dizzy spells, presyncope and syncope episodes, the failure to include any notation related to the Veteran nearly drowning in service weighs as evidence against the Veteran’s assertion. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder). The Board notes that the July 2018 statement from an active duty Navy Petty Officer first class; and the research submitted by the Veteran in July 2018 are insufficient to corroborate his claim that he was classified as a fourth-class swimmer after he nearly drowned during a swim test and feared for his life, because they did not specifically address the Veteran’s experience in service or the Veteran’s military personnel records. In addition, the November 1984 Water Survival Qualification statement; which was signed by the Veteran, is also insufficient to corroborate the Veteran’s claim that he was classified as a fourth-class swimmer after he nearly drowned during a swim test and feared for his life, because it did not discuss the results of the Veteran’s swim test or the alleged incident. Post service treatment records reflect substance abuse treatment from December 1997 and treatment for mental health symptoms from September 2010. A January 2001 VA treatment record indicates that the Veteran reported that he had his last drink in December 2000 and he quit using drugs in 1998. In September 2010, a VA treatment provider noted that based on a clinical evaluation and history, the Veteran did not meet the clinical criteria for a depression diagnosis. The treatment provider noted that the Veteran had a number of symptoms that he wanted relief from. The treatment provider noted that the Veteran engaged interpersonal distancing, had trouble sleeping, had moderate anxiety related to his relationship with his current spouse, his exes (because of his children) and job stressors. The treatment provider noted that the Veteran denied any anger problems, and noted that the Veteran’s mood was anxious and irritable. Regarding a PTSD clinical evaluation, the treatment provider noted rule out (R/O) PTSD. The Veteran reported that he was forced to take a swim test when he was sick and almost drowned in the military. The Veteran reported that he had a flashback when he recently went to a water park and went down the slide into a deep pool and panicked. (The Board notes that during a recent November 2018, the Veteran denied making the statement about a flashback to the treatment provider in 2010.) In September 2010, the Veteran reported that he had been suffering with PTSD for over 20 years, and felt he needed help, because he was suffering from nightmares, sleep impairment, irritability and alcohol abuse. The Veteran also reported that he had been experiencing anxiety, social withdrawal, and nightmares for years, but denied any history of inpatient or outpatient psychiatric treatment. The Veteran also reported that he completed in SARP in the late 1990s, and relapsed afterward. His last use of cocaine was in 2000. He reported that he would occasionally drink about once a month, and he denied any other current substance or tobacco use. The Veteran also reported that he had been hit by a car twice, and lost consciousness both times, once as a teenager and once as a young adult. An August 2015 private treatment record reflects a diagnosis of depressive disorder, not elsewhere classified from November 2011; and a VA treatment record reflects a diagnosis of PTSD from May 2018. As noted, the Veteran did not seek treatment for mental health symptoms until September 2010, nearly 25 years after service, and nearly 10 years after the Veteran reportedly stopped using drugs and abusing alcohol. The Veteran first filed a compensation and pension request in August 2016, over 30 years after service, and over 16 years after the Veteran reportedly stopped using drugs and using alcohol, despite contending that the symptoms of an acquired psychiatric disorder began in service and continued on after leaving service. While not dispositive, the passage of so many years between discharge from active service and the objective documentation of a claimed disability is a factor that weighs against a claim for service connection. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Based on the evidence of record, the Board finds that the Veteran does not have a current psychiatric disability, which was related to a period of active duty service. The Veteran submitted a Mental Disorder Disability Benefits Questionnaire (DBQ) in October 2017, which reflected a diagnosis of moderate-severe mood disorder due to known physiological condition with depressive features. The Veteran reported that he experienced a near-death drowning incident during a training exercise in service. The near drowning event during boot camp caused him so much pain and anxiety that the Veteran was unable to complete A school. Months later the Veteran was medically separated from service, and the Veteran subsequently struggled with anxiety and panic episodes where he was in constant fear of his life. The Veteran reported that he was very forgetful and had problems remembering information at work, and that his conditions caused him to experience poor judgment as he was tired most days. The Veteran also stated that he felt off balance and disoriented. The examiner opined that it was at least as likely as not with a 50 percent probability or greater, that the Veteran developed a chronic mood disorder due to the horrific drowning event suffered during military service. In determining the weight assigned to this evidence, the Board looks at factors such as the health care provider’s knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, supra. The Board finds that the October 2017 DBQ lacks probative value, as it relied on the Veteran’s uncorroborated assertion that he nearly drowned in service and it was not supported by a reasoned analysis. See Wood, supra; Nieves-Rodriguez, supra. The examiner did not discuss the Veteran’s military personnel records which reflect that the Veteran was discharged from the military due to a pre-existing medical condition, syncope and presyncope associated with previous head trauma and the Veteran’s service treatment records which reflect that the Veteran reported that he had symptoms of mild memory loss, trouble concentrating, decreased attention span, dizziness, presyncope and syncope prior to service. The examiner also did not discuss post service treatment records which reflect that the Veteran engaged in drug and alcohol abuse. The Veteran submitted a Mental Disorder DBQ in December 2017, which reflected a diagnosis of recurrent severe major depressive disorder, and generalized anxiety disorder with panic attack specifier. The Veteran reported that he almost drowned during a training exercise while in the Navy boot camp in 1985. The examiner noted that the Veteran had a history of self-medicating with alcohol to decrease symptoms of depression and anxiety, possibly PTSD, and had three DUI convictions in 1991, 1997 and 2013. The examiner noted that the Veteran’s symptoms included paranoia and poor concentration. The examiner opined that the Veteran’s post-military poly substance abuse appeared to be a direct correlation to self-medicating to decrease intrusive, distressing thoughts and images of traumatic event. The examiner opined that it was at least as likely as not that the Veteran’s mental disorders were due to the traumatic event of almost drowning while serving in the United States Navy. The Board finds that the December 2017 DBQ lacks probative value, as it relied on the Veteran’s uncorroborated assertion that he nearly drowned in service, was not based upon all the relevant medical facts, and was not supported by a reasoned analysis. See Wood, supra; Nieves-Rodriguez, supra. Although the examiner opined that the Veteran post military poly substance abuse appeared to be a direct correlation to self-medicating; the examiner did not discuss the November 1984 Report of Medical History for enlistment, which reflected that the Veteran reported using marijuana prior to service. Additionally, the Board notes that the Veteran failed to disclose to the examiner that he had also been drinking prior to service. The examiner also did not discuss whether the Veteran’s symptoms of paranoia were related to his drug and alcohol abuse. Additionally, the examiner did not discuss the Veteran’s service records which reflect that the Veteran was discharged from the military due to a pre-existing medical condition, syncope and presyncope associated with previous head trauma; and the Veteran’s service treatment records which reflect that the Veteran reported symptoms of trouble concentrating and decreased attention span prior to service. In January 2018, the December 2017 examiner provided an addendum opinion. The examiner opined that based on a review of the Veteran’s medical service records, it was at least as likely as not, more than 50 percent probability that the syncope that the Veteran was diagnosed with during his military service was due to fear, stress, and anxiety after nearly drowning during boot camp. The examiner noted that “due to the emotional stress of boot camp coupled with the trauma of nearly drowning is supported by research the indicates a correlation between a traumatic event and syncope.” The psychological stress of the near drowning and the resulting syncope contributed directly to the Veteran’s current diagnosis of generalized anxiety with panic attacks. The Board finds that the January 2018 addendum opinion lacks probative value, as it relied on the Veteran’s uncorroborated assertion that he nearly drowned in service and it was not supported by a reasoned analysis. See Wood, supra; Nieves-Rodriguez, supra. Although the examiner opined that based on a review of the Veteran’s medical service records, it was at least as likely as not, more than 50 percent probability that the syncope that the Veteran was diagnosed with during his military service was due to fear, stress, and anxiety after nearly drowning during boot camp; the examiner did not discuss the Veteran’s service records which reflect that the Veteran was discharged from the military due to a pre-existing medical condition, syncope and presyncope associated with previous head trauma. The examiner also did not discuss the service treatment records, which reflect that the Veteran admitted to recurrent dizzy spells, presyncope and syncope episodes, and recurrent transient episodes of memory loss prior to service. In April 2018, the December 2017 examiner provided a letter in support of the Veteran’s claim, which reflected a diagnosis of recurrent severe major depressive disorder and generalized anxiety disorder with panic attacks. The examiner noted that she had been meeting the Veteran weekly for approximately 16 months. The examiner noted that the Veteran’s symptoms had continued since manifesting after the incident of near drowning while in Navy boot camp. The examiner opined that it was at least as likely as not that the Veteran first exhibited symptoms of anxiety and depression while serving in the military. Specifically, his symptoms started during the time in the Navy after nearly drowning during a training exercise at boot camp and have existed continuously from that time until the present. The Board finds that the April 2018 opinion also lacks probative value, as it relied on the Veteran’s uncorroborated assertion that he nearly drowned in service and it was not supported by a reasoned analysis. See Wood, supra; Nieves-Rodriguez, supra. Although, the examiner opined that it was at least as likely as not that the Veteran first exhibited symptoms of anxiety and depression while serving in the military; the examiner did not discuss which of the Veteran’s service treatment records supported a finding that the Veteran exhibited symptoms of anxiety and depression in service; and the examiner did not discuss the September 1985 Medical Board Report, which reflects that the Veteran denied easy irritability. The Veteran was afforded a VA examination in May 2018, which reflected a diagnosis of major depressive disorder and unspecified anxiety disorder. The Veteran reported that he was discharged due to having frequent dizzy spells. He stated that he almost drowned during the second week of boot camp, during a swimming test. He stated that he was not sent to sick call and was messed up the entire day. The Veteran also reported another time, he had a dizzy spell and hit his head on the bathroom floor, he went to sick call and they sent him back to duty. He stated that he never experienced any dizzy spells until after his drowning incident, and he denied having any related issues prior to service. He stated that he began drinking after he almost drowned, and he was discharged from service due to the syncope. He stated that he had been a nervous wreck ever since then. The Veteran also reported that he had been hit by a car in 1979, and had a concussion prior to service. He reported that the Navy stated that the syncope was due to the head trauma six years later. The examiner opined that the Veteran’s condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the Veteran’s reported symptoms were consistent with his personal reported stressors (i.e., drowning incident) while in service and he denied pre-military history of mental health problems. The Board finds that the May 2018 VA examination lacks probative value, as it was based on the Veteran’s uncorroborated assertion that he nearly drowned in service and the opinion was based in part upon an inaccurate factual premise. See Wood, supra; Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (“If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely”) (citing Reonal)). Specifically, the Veteran told the VA examiner that he never experienced dizzy spells until after his alleged near-drowning in service. However, this statement contradicts his multiple contemporaneous reported histories during service to the effect that he had recurrent dizziness/syncope for years, ever since two pre-service head traumas. He also told the examiner that he did not know he had syncope at separation, but the record shows that he previously filed VA disability claims for syncope, including in July 1989. Furthermore, although the Veteran told the examiner that he was a “nervous wreck” ever since the alleged incident, the examiner failed to comment on the fact that the service treatment records are entirely negative for psychiatric complaints, the Veteran explicitly denied any psychiatric symptoms in September 1985, and his psychiatric system was normal on examination in October 1985. Additionally, although the Veteran reported to the examiner that he began drinking after he almost drowned; in a November 2018 statement, the Veteran acknowledged that he began drinking prior to service. These inconsistencies greatly reduce the credibility of his current statements and the probative value of the opinion which relied on these statements. In July 2018, the December 2017 examiner opined that the Veteran’s pre-service syncopal episodes had no bearing on the post-service mental disorders brought on by the near drowning Navy boot camp. The examiner noted that the opinion was based upon a review of the Board remand letter, case law cited, the Veteran’s entire claim file, and meetings with the Veteran. The examiner noted that the Veteran’s stressful experience was encountered during the boot camp swimming exercise, and he reported that no assistance was provided after the traumatic event. However, he was later subjected to derogatory comments by leaders regarding his inability to swim. The examiner noted that the Veteran’s history of suicidal ideations, self-medication with drugs and alcohol, episodes of depression, anxiety with panic attacks when encountering situations he could not control, sleep disturbance, and nightmares related to near drowning, were symptoms of PTSD with depression. The examiner noted that the Veteran continued to require ongoing therapy to manage his symptoms of depression and anxiety. The examiner opined that based on a review of the Veteran’s entire claims file, Board remand letter, and therapy sessions, it was at least as likely as not that the current diagnosed condition (major depressive disorder, recurrent, severe and generalized anxiety disorder with panic attacks) was due to the Veteran’s nearly drowning at boot camp in service. The Board finds that the July 2018 opinion also lacks probative value, as it relied on the Veteran’s uncorroborated assertion that he nearly drowned in service, it was not based on all the pertinent facts, and it was not supported by a reasoned analysis. See Wood, supra; Nieves-Rodriguez, supra. Although the examiner opined that the Veteran’s self-medication with drugs and alcohol was a symptom of PTSD with depression, the examiner did not discuss the November 1984 Report of Medical History for enlistment, which reflected that the Veteran reported using marijuana prior to service. Further, the Board notes that the July 2018 opinion was based on an incomplete statement of the facts. Notably, in November 2018 the Veteran admitted that he used alcohol prior to service. In October 2018, the May 2018 VA examiner provider an addendum opinion. The examiner opined that the Veteran’s claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran’s reported symptoms were consistent with his personal reported stressors (i.e., drowning incident) while in-service, and the Veteran denied pre-military history of mental health problems. The Board finds that the October 2018 addendum opinion lacks probative value. The Board notes that the examiner restated the previous May 2018 VA examination, and did not address the Veteran’s inconsistent statements. The Veteran was afforded a VA examination in November 2018, which reflects that the Veteran’s symptoms were related to a sequelae of heavy drug use, but did not warrant a psychiatric diagnosis. The examiner opined that the Veteran did not meet the clinical criteria of PTSD, anxiety disorder, depressive disorder, or adjustment disorder; however, the Veteran presented the picture of sequelae heavy drug use over many years. The examiner noted that the Veteran had an extensive history of using crack, alcohol, and PCP since at least 1985. The examiner noted that the Veteran had been diagnosed with depressive disorder and anxiety disorder by a VA examiner and adjustment disorder by a private examiner, who noted that the Veteran could be quite inconsistent. The examiner noted that that prior examiners did not discuss the Veteran’s extensive history of hallucinogenic drugs. The examiner noted that when someone has such a history, it is often the case that the person will develop depressive symptoms secondary to drug use, impaired and altered memories, paranoia and hallucinations, which persist even after drug use has stopped. Finally, the examiner noted that the Veteran had sleep apnea, and used his mask inconsistently, which also complicated his interrupted sleep. Therefore, the examiner opined that it was more likely than not that the Veteran’s diagnostic picture was a product of heavy drug use for many years in someone who may have already had some mental weakness due to head injuries when he was young. The examiner also noted that when he spoke with the Veteran in an open-ended, and non-suggestive way, it appeared that what was bothering him, had nothing to do with being in the water while not knowing how to swim well. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for an acquired psychiatric disorder, to include depressive disorder and PTSD have not been met. Based on the evidence as outlined above, service connection for PTSD is not warranted in this case, as there is insufficient evidence to corroborate the Veteran’s claim that he nearly drowned in service and feared for his life. In addition, service connection for an acquired psychiatric disorder to include depressive disorder is not warranted as there is no evidence that the Veteran has a current psychiatric condition which began in service. The Board notes that the Veteran is competent to report that he has memory loss, depression, suspiciousness, trouble sleeping, panic attacks, suicidal ideation and anxiousness. See Barr v. Nicholson, 21 Vet. App. 303, 307-308 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran is also competent to report that he began experiencing these symptoms during service after he nearly drowned in service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). In this regard, the Board highlights that competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It is within the Veteran’s realm of personal knowledge whether he has experienced memory loss, depression, suspiciousness, trouble sleeping, panic attacks, suicidal ideation and anxiousness during service and has experienced those symptoms since service. However, in adjudicating this claim, the Board must assess not only competency of the Veteran’s statements, but also their credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (Fed. Cir. 2006). The overwhelming evidence in the record supports that the Veteran is an unreliable historian. The Veteran’s description of his nearly drowning in service during a swim test was not confirmed by any of his service treatment records, despite reporting that he was ranked as a fourth-class swimmer. Considering the documented recitation of the Veteran’s history of treatment during service for dizziness, syncope and presyncope symptoms, an incident where the Veteran had nearly drowned during a swim test would have been expected to be recorded in his medical records. See Kahana, supra. Further, the Board notes that in relation to the Veteran’s pre-existing syncope and presyncope, the Veteran underwent a series of evaluations, and the treatment provider even noted that the Veteran denied having easy irritability, and there was no indication that the Veteran had any other neurological problems. To the extent that the Veteran is also asserting that he had depression and anxiety that began in-service, separate from his reported symptoms of memory loss, trouble concentrating, and decreased attention span, the Board also finds that assertion is not credible. The Veteran has made contradictory statements regarding the onset of his memory problems. As noted, he has asserted both that his memory loss began after he nearly drowned in service, and that his memory loss was due to his pre-service head injuries. However, the Veteran’s service treatment records reveal that the Veteran reported that his memory loss, trouble concentrating and decreased attention span began prior to service, and make no mention of the Veteran having any psychiatric symptoms, including anxiety or depression during service. The above tends to demonstrate that the Veteran’s lay assertions regarding his in-service history of anxiety and depression to be unreliable, and therefore not credible. The absence of any in-service reports of injury, complaint, finding, or reference to treatment related to nearly drowning in service, under the facts of this case, is one factor, among other factors considered by the Board, including no post-service symptoms or diagnosis of PTSD, depression or anxiety until years after service, weighs against finding an in-service stressor sufficient to cause PTSD. See Buczynski v. Shinseki, 24 Vet. App. 224 (2011) (the absence of a notation in a record may only be considered if it is first shown that the record is complete and also that the fact would have been recorded had it occurred); Kahana, supra. As noted, the Veteran did not initially seek treatment for a mental health condition until September 2010, nearly 25 years after service, and at least 10 years after he reportedly stopped using drugs and abusing alcohol. The Veteran did not file his claim for service connection for a psychiatric condition until 2016, more than 30 years after service, and at least 16 years after he reportedly stopped using drugs and abusing alcohol. Further, as noted, the Veteran initially claimed that his symptoms of memory loss and trouble concentrating were due to PTSD, and later admitted that during service those symptoms had been attributed to his pre-service head injuries. In response to the June 2018 Board remand; the Veteran stated in July 2018, that he had a head injury in 1979 and in 1980, and the Navy discharged him for syncope from the previous head trauma, which existed prior to service. The Veteran stated that he did not feel that this was in any way related to his currently diagnosed mental disorder, due to nearly drowning at boot camp in the Navy. The Veteran stated that following his May 2018 VA examination, he left a note to the examiner regarding his pre-service head injuries and syncopal episodes. He stated that he intended to say that the pre-syncopal episodes that he experienced prior to service were due to his diagnosed pre-service hypotension and were not related to his traumatic near drowning incident. The Veteran stated that he merely forgot, as one of the symptoms that he was challenged with was memory loss or memory lapses, which was also documented in a September 1985 service treatment record. The Veteran stated that the syncope which existed prior to service became more severe after the incident of nearly drowning, and he even passed out from a syncopal occurrence, days after the near drowning incident and hit his head. The Board finds however, that the assertion by the Veteran that he intended to say that the pre-syncopal episodes that he experienced prior to service were due to his diagnosed pre-service hypotension and were not related to his traumatic near drowning incident is contradicted by the Veteran’s earlier January 2018 statement that a treatment provider told him that his syncope, which he had been discharged for, had been causing him to pass out, and it was related to stress and his stressor. He stated that he had been suffering from depression and anxiety since service due to the incident of almost drowning at boot camp. In addition to making contradictory statements regarding the onset of his syncope and presyncope conditions, the Veteran also inaccurately stated that he began using drugs after his alleged injury in service. In July 2018 and November 2018, the Veteran stated that he began drinking heavily after he nearly drowned in service. In November 2018, the Veteran also acknowledged that he drank alcohol before enlistment in service, but not as much as he did after nearly drowning. Further, in November 2018, the Veteran stated that he began using drugs after his discharge from service. However, as noted, a November 1984 Report of Medical History for enlistment reflects that the Veteran reported using marijuana prior to service. The November 2018 statement and the November 1984 Report of Medical History indicate that the Veteran’s drug and alcohol use began prior to service, which the Veteran failed to disclose to examiners. As noted, in September 2010, the Veteran reported to a VA treatment provider that he had a flashback at a water park that triggered memories of his near drowning experience in service. Then in October 2016 the Veteran stated that he could no longer go into deep water and he panicked one day after attempting to go snorkeling. The Veteran did not mention the flashback he had at the water park. In May 2017, the Veteran’s former spouse stated that the Veteran suffered a panic attack in the water when he attempted to go on a snorkeling tour with her in the ocean. Then, most recently, during the November 2018 VA examination, when the examiner asked the Veteran about a 2010 psychology note which indicated that the Veteran had a flashback to the incident in the Navy, the Veteran denied he ever told anyone before about the incident. The fact that the Veteran was not truthful about the circumstances of his discharge from service and his pre-existing diagnosis of syncope and presyncope; made contradictory statements regarding his drug and alcohol use prior to service; and made contradictory statements regarding his recollections of nearly drowning in service, generally tends to make his assertions about his claim that he nearly drowned in service less credible. Based on the foregoing, the Board finds the Veteran has not presented any competent and credible evidence that he nearly drowned in service or that his symptoms of depression and anxiety had their onset during service. As noted, the Board finds that the October 2017 DBQ, December 2017 DBQ, January 2018 addendum opinion from the December 2017 examiner, April 2018 letter from the December 2017 examiner, May 2018 VA examination, July 2018 opinion from the December 2017 examiner, and the October 2018 addendum opinion from the May 2018 VA examiner lack probative value in determining whether the Veteran is entitled to service connection for an acquired psychiatric condition. The opinions were based upon the Veteran’s self-reported history of nearly drowning in service, which the Board has not found credible, were not supported by an adequate analysis of the Veteran’s service treatment records, notably, none of the examiners discussed the Veteran’s use of marijuana prior to service, and the examiners were not fully informed of the pertinent facts, including the fact that the Veteran began drinking prior to service. In contrast, the November 2018 VA opinion indicating that the Veteran’s symptoms were related to a sequelae of heavy drug use, and the Veteran did not have a current psychiatric diagnosis, was supported by a thorough analysis of the Veteran’s medical treatment records, including his service treatment records and post service treatment records. The November 2018 VA examiner provided a fully articulated opinion, and furnished a reasoned analysis. The Board therefore attaches significant probative value to this opinion and the most probative value in this case, as the opinion was well reasoned, detailed, and consistent with other evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-449 (2000). Accordingly, as there is no competent and credible evidence of the onset of symptoms of anxiety or depression in service or of the Veteran nearly drowning in service, the Board finds that entitlement to service connection for an acquired psychiatric disorder, including depressive disorder and PTSD is not warranted. Based on the evidence as outlined above, the Board finds that the evidence of record weighs against a finding of a nexus between the Veteran’s claimed acquired psychiatric disorder, to include depressive disorder and PTSD and his active military service. The Board notes that under the provisions of 38 U.S.C. § 5107(b), the benefit of the doubt is to be resolved in the claimant’s favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran’s claim, and thus, that doctrine is not applicable. The Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder and PTSD is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. The Veteran seeks service connection for sleep apnea, which he asserts is related to service. In May 2017, the Veteran stated that his sleep apnea was due to military service, and that he started snoring in the military. VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claims. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The requirement that the evidence “indicates” that the Veteran’s disability “may” be associated with his service is a low threshold. Id. Thus, in light of the Veteran’s contentions and the record on appeal, a VA examination should be obtained to determine the probable etiology of the Veteran’s sleep apnea, to include whether the Veteran’s sleep apnea is related to service. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon, supra. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s sleep apnea. All necessary tests should be conducted. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should address whether it is at least as likely as not (50 percent or greater likelihood) that any current sleep apnea manifested during, is otherwise causally or etiologically related to a period of active duty service. The examiner should consider and discuss the following: (a.) The Veterans statements regarding his sleep apnea condition; See May 2017 and July 2018 statements; (b.) Post service treatment records which reflect that the Veteran reported problem sleeping from September 2010;. In rendering the opinions, the examiner should consider the Veteran’s statements regarding the symptoms of sleep apnea to be credible and competent. (Continued on the next page)   The examiner should provide a complete rationale for all opinions expressed and conclusions reached. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Johnson, Associate Counsel