Citation Nr: 21003306 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 17-19 416 DATE: January 21, 2021 ORDER Entitlement to service connection for acquired psychiatric disorder, variously diagnosed, is denied. FINDING OF FACT The objective medical evidence shows an acquired psychiatric disorder, variously diagnosed, is not caused by an event, injury, or illness during active service, nor did a psychosis manifest to a compensable degree within one year of separation from active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, variously diagnosed, have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Navy from August 1988 to August 1989. In August 2017, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This issue was remanded for development in January 2019. It has been returned to the Board for appellate review. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active service or that a preexisting injury or disease was aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2019). Establishing service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases, including a psychosis and/or arthritis, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period after service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing and in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson v. West, 12 Vet. App. 247, at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). Entitlement to service connection for acquired psychiatric disorder, variously diagnosed. The service treatment records (STRs) show in four treatment notes between May 10 and May 24, 1989, the Veteran was referred to the Fleet Mental Health Branch Clinic for interviews and a psychiatric consult. Treatment providers noted the Veteran was a poor worker, unable to accomplish the simplest of jobs, unable to grasp what is happening around him, and therefore a “target” for others in his division. The Veteran was further noted as appearing depressed, highly stressed and always exhibiting unacceptable personal hygiene. Further interview with the Veteran indicated low self-esteem and details of a traumatic childhood from his earliest infancy. One treatment provider rendered no diagnosis, but noted to “rule out” adjustment disorder with depression and intent to hurt himself. A second treatment provider’s diagnostic impression included “occupational problem, developmental arithmetic disorder and avoidant traits.” Although found fit for duty by one treatment provider, he recommended a Chaplain’s program, Jacobson relaxation exercises and self-help books. In June 1989, the Veteran injured his neck and back in an altercation with another seaman. Later in June, the Veteran was seen again in the mental health clinic for a re-evaluation for a psychiatric condition. The treatment provider noted he appeared depressed and was not practicing proper personal hygiene. On this date he went before a non-judicial punishment (NJP) board after making a racial slur to other servicemembers and for not following an order. It was noted that he should be separated as his “command couldn’t babysit him.” Each charge repeatedly had to be explained to the Veteran, as he appeared unable to understand them. The treatment provider’s assessment was “R/O [Rule Out] Personality Disorder.” In July 1989, the Veteran was struck in the face after an argument with another seaman. In August 1989, a treatment note outlines a pattern of the Veteran’s disruptive behavior, degraded hygiene and unresponsiveness to counseling and assistance. Once again, he was assessed with R/O personality disorder. That day’s follow-up psychiatric evaluation states the Veteran was noted as persisting in a pattern of uncleanliness and an inability to work with others. His hygienic habits were noted as having degenerated to a point at which he had to report to the medical personnel for supervised daily showers, but afterward his hygiene would quickly deteriorate to a non-showered condition. The Veteran was further noted as persisting in agitating others with words, gestures and actions, then blaming others for the resulting trouble. The note concluded that the Veteran is totally unable to fit in the shipboard environment or work with others “and is unable to comprehend, understand, learn, or benefit from instruction or supervision. In an August 1989 follow-up visit to the Fleet Maintain Health Unit at the Naval Medical Clinic in San Diego, California, the treatment provider noted that “command apparently is processing him for discharge….” The treatment provider diagnosed: “Axis I: 1. Occupational problem, 2. Other-specified family circumstances (childhood physical abuse). Axis II: 1. Developmental arithmetic disorder. 2. Personality disorder, not otherwise specified, with avoidant, passive-aggressive features, EPTE [existed prior to enlistment], unsuitable for United States Navy.” His recommendations stated: “The member is not considered mentally ill, but manifests a longstanding disorder of character and behavior which is of such severity as to tender the individual incapable of serving adequately in the Navy. The member does not presently require and will not benefit from hospitalization or psychiatric treatment. Although the member is not presently considered suicidal or homicidal, the member is judged to represent a continuing risk to self or others if retained in the Naval Service,” adding that the Veteran is fit for immediate processing for administrative separation. The August 1989 separation examination shows the category of psychiatric was found to be normal, but notes were added stating the Veteran was separated for a personality disorder, without suicidal or homicidal ideation and that he had been seen by Fleet Mental Health. The Veteran was further noted as electing separation from service and to “seek VA help.” The post-service record shows in May 1995, the Veteran was admitted to a local hospital with complaints of suicidal ideation. The Veteran’s reports indicated his concerns focused on difficulties with his ex-wife and her boyfriend seemingly “replacing” him as the father of his children. The treatment provider prescribed medications and was confident the Veteran was not acutely suicidal. He denied delusional thinking, hallucinations and exhibited no other signs of psychosis. His discharge diagnoses were major depression with melancholia, rule out major depression with psychotic feature and rule out schizoaffective disorder; passive dependent personality; and psychosocial stressor, recently divorced, severe. However, in late May or early June 1995, the Veteran spent two weeks in the psychiatric unit of the hospital for suicidal ideation and major depression. Later in June 1995, the Veteran was again admitted to the local hospital with an admitting diagnosis of unspecified neurotic disorder. A later diagnosis stated, “major depressive affective disorder, recurrent episode, severe, without psychotic behavior.” The Veteran’s chief complaint was ‘I feel like killing myself.” He underwent individual and group daily therapy. Later in June 1995, the Veteran underwent another hospital stay for both individual and group psychiatric counseling for approximately two days. The Veteran’s behavior indicated to the treatment provider he was depressed, anxious, hypomanic (excessive talking and rapid actions), prone to irritability, shortness of temper, impulsive urges, tends to interrupt the group, and has some difficulty sleeping. He otherwise denied hallucinations, paranoia and suicidal thoughts. In July 1995, his treatment provider diagnosed major depression with melancholia. The Veteran was admitted again September 1995 with suicidal ideation for approximately one week. He participated in daily supportive therapy and he was prescribed medications. The treatment provider diagnosed him with major depression with melancholia, inadequate personality and psychological stressors (son almost killed in a medication accident), which remained as the discharge diagnosis. In January 1996, the Veteran was admitted to the hospital for suicidal ideation. He denied any hallucinations. The treatment provider noted the Veteran’s reports he was compliant with medications; however, after feeling better, he stopped taking the medications. The discharge diagnosis was major depression melancholia “but in the future may turn out to [be] schizoaffective disorder or schizophrenia;” schizoid personality; psychological stressor (loss of job, difficulties with his mother). At the end of June 1996, the Veteran was admitted to hospital after reporting a voice was telling him to get out of the car while it was still “running,” indicating to himself that he was suicidal. The Veteran reported he was married in the prior month and he has 2 sons from his prior marriage. He exhibited manic symptoms. The Veteran was admitted to the hospital in July 1996 for approximately a week. The Veteran complained of severe depression, confusion, paranoia, auditory hallucinations, and suicidal thoughts with an explicit plan, as well as having current problems with his mother. The treatment provider diagnosed schizophrenia, schizoaffective [sic], depressed, which remained as the discharge diagnosis with the addition of multiple stressors regarding a girlfriend. During treatment for this stay, he exhibited depression, as well as some manic symptoms. In late July 1996, the Veteran was admitted to what appears to be a different hospital for severe anxiety, agitation and depression. He reported difficulties with his mother. The treatment provider prescribed medications. The Veteran reported he had no children. His treatment provider diagnosed dysthymic disorder. However, three days later, after medications helped him to become more calm, the Veteran demanded his immediate release. The treatment provider noted that, since the Veteran was free from psychotic symptoms or dangerous tendencies, he granted the release against medical advice, additionally because the Veteran did not qualify for involuntary commitment. On discharge, the Veteran was noted as being at a fair level of function, but had exhibited poor cooperation. He received no prescription and was advised to continue to follow-up at the Mental Health Clinic. It appears from the record he was immediately re-admitted the day of his discharge, with a specific intent to cut his wrists with razor blades. The treatment provider noted that although the Veteran is threatening suicide, “I don’t know if this is manipulatory or if he really means he will do that.” He prescribed medications and scheduled the Veteran for supportive psychotherapy, group therapy and other modalities off treatment. The Veteran was again admitted to his first hospital in September 1996 with depression and suicidal ideation. He did not exhibit delusions or hallucinations. The treatment provider diagnosed “[s]chizophrenia, schizoaffective, depressed.” He was again admitted in late October 1996 for severe anxiety, depression, agitation, confusion, paranoid delusional thinking, and suicidal thoughts with intentions to cut himself with a knife. The Veteran improved with medications and wanted to return home. He was diagnosed with schizoaffective disorder. The Veteran was hospitalized in March 1999 with complaints, symptoms and diagnosis overall identical to those shown in the record between 1995 and 1996. In January 2001, the Veteran applied for admission to the adult psychiatry unit of a local hospital, where he was diagnosed with psychosis, history of schizoaffective disorder and learning disability in math. In April 2002, he received a diagnosis of schizophrenia undifferentiated, depression and personality disorder. In January 2003, the Veteran received diagnoses of depression, NOS (not otherwise specified), history of pathological gambling and borderline personality disorder. In a March 2003 psychological evaluation conducted in connection with the Veteran’s application for Social Security benefits, the psychologist concluded the Veteran has adequate intellect to follow directions, interpersonal function is diminished and is moderately impaired to meet the demands of competitive adult employment. He diagnosed the Veteran with schizoaffective disorder with fair remission and borderline intellectual functioning. In a September 2003, a Mental Residual Functional Capacity Assessment, also conducted in connection with the Veteran application or Social Security benefits, Dr. N.M.C. found the Veteran enjoys activities requiring concertation, but at a slowed pace, he gets along with others for the most part and he can function effectively in predictable settings. She concluded that the Veteran “is limited by his affective and personality disorder traits, but not to any level near significant.” The Veteran continued with psychiatric treatment throughout 2005, 2006 and 2007. In Dr. S.P.’s March 2005 clinical interview – mental status examination, conducted in connection with further application for Social Security benefits, shows a diagnosis of “[n]o mental disorder” and borderline intellectual functioning. However, another mental health professional in a June 2005 psychiatric evaluation diagnosed bipolar disorder, “most recent episode mixed severe with psychotic features.” In this period, although diagnosed with bipolar disorder, there is no documentation of the Veteran’s hospitalization during a manic episode, nor is there documentation of the length of the Veteran’s mood swings. In January 2008, the Veteran was adjudged disabled by the Social Security Administration, based on his impairments of schizophrenia and affective disorder. In August 2011, a mental health treatment provider noted the Veteran’s reports that he had had no hospitalizations in 14 years. In treatment between August 2011 and September 2012, the Veteran’s most prominent psychiatric concern appears to have been depression. Moreover, in August 2011, he reported that he had “problems” with bipolar disorder since 1994. In May 2012, a physician examined the Veteran in connection with his application for county or state benefits and diagnosed the Veteran with bipolar, type I (w[ith] psychotic features). He briefly added that symptoms “worsened due to service.” In January 2013, the Veteran underwent a VA examination for mental disorders, in which the relevant diagnoses included personality disorder, NOS and psychosocial and environmental problems. The VA examiner noted at length the Veteran’s reported history of active service in the Navy, occupational history and family history, most of which has been set forth above. The VA examiner from his review of the record further noted in detail the Veteran’s in-service treatment and disciplinary history and post-service mental health treatment history. The January 2013 VA examiner noted that the record shows the Veteran has received a variety of diagnoses. “To clarify the current diagnostic picture,” he administered the Millon Clinical Multiaxial Inventory-III (MCMI-III) and the Minnesota Multiphasic Personality Inventory-2 Short Form (MMPI2-S). The results indicated the presence of several clinically significant personality traits and at least two of these scales came very close to indicating the presence of a “clinically significant personality disorder.” He concluded that, based on that day’s psychological testing, the diagnosis of personality disorder, NOS appears most appropriate. Although misstating the date, the January 2013 VA examiner further noted that the May 2012 physician’s conclusion, stated above, that the Veteran symptoms were “worsened due to service.” He observed, “No rationale or elaboration of this notation is present in the medical notes. This is the first and only statement linking his mental illness to his military service that could be found in the veteran’s C-file.” The January 2013 VA examiner concluded that none of the Veteran’s in-service treatment providers diagnosed him with an acquired psychiatric disorder, his post-service hospitalizations were “responses” to various circumstantial stressors (child custody issues, post-divorce issues and job loss) and “limited intellectual resources and personality disorder” were pre-existing factors that likely contributed to his inability to adapt to the Navy. Based on the foregoing, he opined that the Veteran’s military service was less likely than not to have caused or aggravated his condition. The Veteran’s medical records show mental health treatment from January 2015 to March 2018 at Coleman Behavioral Health in Warren, Ohio. A June 2015 treatment note shows the Veteran reported he had one prior psychiatric hospitalization 16 years prior for “bipolar” and had taken no medications since 2012. He was diagnosed with bipolar disorder, NOS. Further records from Coleman Behavioral Health show 2017 diagnoses of disruptive mood dysregulation disorder, mild dementia due to organic brain syndrome or cerebral vascular accident, other psychotic disorder not due to a known substance or physiological condition, and a provisional diagnosis of mood disorder due to a known condition, with depressive features. In a February 2017 VA examination for mental disorders, the VA examiner diagnosed unspecified bipolar and related disorder, in full remission. He found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The February 2017 VA examiner fist opined that the Veteran meets the diagnostic criteria for unspecified bipolar and related disorder, in full remission, based on the criteria set forth in the American Psychiatric Association’s DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5th Edition (DSM – V), the diagnosis being based on a documented history of major depressive episodes and the Veteran’s report of hypomanic episodes , which the VA examiner did not conclude were documented well enough to determine if he meets criteria for bipolar I disorder or bipolar II disorder. He added, “There were some psychotic symptoms (command hallucinations) noted over 20 years ago but not since. Given the absence of psychotic symptoms for over 20 years, despite not taking psychiatric medications for several years, a diagnosis of any psychotic disorder is unwarranted.” The February 2017 VA examiner next opined: It is not as least as likely as not that the veteran has “a diagnosis of bipolar disorder, affective disorder, mood disorder, or any psychiatric disorder that was incurred in or caused by the mental health symptoms, listed in service records as a rule-out diagnosis of adjustment disorder with depression.” The rationale for this opinion is the following: 1. The veteran was not diagnosed with any mental condition during military service except for a personality disorder, nor did he receive any mental health treatment in the Navy. A rule-out diagnosis is not an actual diagnosis. 2. By DSM-IV [4th edition] or DSM-5 definition, an adjustment disorder is time-limited to a brief period of time after the precipitating stressor ends. If the veteran did in fact have an adjustment disorder in service (which in my opinion was a more accurate diagnosis than the personality disorder diagnosis given at discharge), the diagnosis of adjustment disorder would not have been continued following cessation of the stressor, which was the demands of military service. Furthermore, there is no evidence during the years immediately after discharge of the symptoms noted in-service as depressive, such as poor hygiene, apathy, and getting into fights. Thus, the in-service symptoms were a temporarily disabling condition in response to in-service stressors, and the condition ceased once the stressors were gone. 3. Although the veteran has variously claimed that he had postmilitary mental health treatment beginning in 1989, 1994, or 2000, the evidence of record does not document any mental health treatment prior to 1994. In other words, there is no collateral evidence supporting continuous mental health treatment or symptoms between leaving the Navy in 1989 and outpatient treatment in 1994. 4. There is no evidence of any psychotic symptoms in the service or afterwards until 1996, five years after military separation, when the veteran reported command hallucinations. There is no subsequent evidence of any psychotic symptoms, including at the present time. 5. The opinion of the veteran’s [May] 2012 treating physician that [the Veteran’s] symptoms were “worsened due to service” is not supported by any rationale, nor is it supported by postmilitary medical records. In January 18, 2019, the Board remanded the claim to obtain an addendum medical opinion in which the examiner was required to identify any and all psychiatric disabilities currently present, then render an opinion on whether any diagnosed disorder had its onset during active service or is etiologically related to service. A VA examination followed in November 2019, in which the diagnosis section includes two different diagnoses of “unspecified bipolar and related disorder” and “unspecified neurocognitive disorder, mild.” The VA examiner noted that depressed mood is attributable to the bipolar disorder and all other symptoms are attributable to the neurocognitive disorder and that the diagnoses “are NOT clinically associated.” He found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. He noted that all of the occupational and social impairment was attributable to the neurocognitive disorder. The November 2019 VA examiner found the Veteran meets DSM-V criteria for bipolar disorder, noting he had not exhibited psychotic symptoms for at least 20 years. However, he opined that it is not as least as likely as not that the Veteran has a current mental health diagnosis that either was incurred in service or is otherwise etiologically related to his service. He explained in his rationale that the only in-service mental health diagnosis was a personality disorder, the Veteran had no mental health treatment in service and there is no evidence of record to document that the Veteran had any mental health treatment until 1994, which was five years after military service ended. He further stated the Veteran’s in-service symptoms are not consistent with an early onset of bipolar disorder, which has been the most consistent mental health diagnosis he has had for decades and there is also no collateral evidence of record that psychotic symptoms occurred either in the service or within a year of discharge. He added: I am unaware of peer-reviewed evidence that any sort of in-service stressor is a likely cause of the onset of bipolar disorder. To the contrary, bipolar disorder is generally viewed by the psychiatric literature as having an unknown cause with several possible non-environmental factors (e.g., abnormal brain structure, genetic factors). Concerning the 2017 diagnosis of disruptive mood regulation disorder by the private psychiatrist (Dr. [A.M., at Coleman Behavioral Health]), this diagnosis is clearly an error, as DSM-5 clearly specifies that this diagnosis is for mood disturbance in childhood under age 12 years. My impression from Dr. [A.M.’s] notes is that he used this diagnosis for the veteran’s pseudobulbar affect, which is a symptom stemming from brain injury or neurological disease; it is not a psychiatric diagnosis. Concerning the diagnosis of a psychotic disorder by Dr. [A.M.] in 2017, there is no evidence of recent psychotic symptoms and none noted in the 2017 progress notes, although there is a remote history of auditory hallucinations over 20 years ago. The non-VA psychiatrist did not feel that the veteran’s report of a prior diagnosis of paranoid schizophrenia was consistent with either [sic] [the Veteran’s] symptoms of history. The veteran has a clinical diagnosis of vascular dementia, which is coded in this DBQ [Disability Benefits Questionnaire] as unspecified neurocognitive disorder, mild. His dementia was diagnosed many years after military service and therefore was not as least as likely as not incurred in or caused by service. In VA mental health notes in March and April 2019, the Veteran’s PHQ – 9 Depression Scale [Patient Health Questionnaire, 9 questions] indicated “no apparent depression.” In a July 2019 review of systems during a telephone interview, the Veteran admitted to memory loss, confusion, vascular dementia, bipolar, neurocognitive disorder, but denied depression, post-traumatic stress disorder (PTSD) or suicidal ideation/homicidal ideation. His PHQ – 9 Depression Scale showed mild depression. On the August 2019 PHQ – 9 Depression Scale at VA, the Veteran showed “minimal” depression. A VA psychiatric note in October 2019 shows the Veteran’s reports of feeling depressed and not sleeping well. On an PHQ – 9 Depression Scale, the Veteran showed “mild” depression. A December 2019 VA mental health note stated the Veteran’s report that his recent physical decline has led to some depression. In a January 2020 review of systems during a telephone interview, the Veteran again admitted to memory loss, confusion, vascular dementia, bipolar, neurocognitive disorder, but denied depression, PTSD, or suicidal ideation/homicidal ideation. On the PHQ – 9 Depression Scale, the Veteran again showed mild depression. Between December 2019 and March 2020, VA psychiatric notes show the Veteran’s reports of his mood being “real good,” energy and motivation being “pretty good” and sleep being “good.” He denied hallucinations, paranoia, manic symptoms, impulsive behaviors, and racing thoughts. In this period, the Veteran’s VA diagnoses also included bipolar disorder. As shown above in the summary of the record, the STRs show no in-service treatment for a psychiatric disorder and, other than “personality disorder,” there is no diagnosis of a psychiatric disorder. The treatment provider at the Fleet Mental Health Unit at the Naval Medical Clinic in San Diego in August 1989, who diagnosed personality disorder, specifically stated in his recommendations that the Veteran “is not considered mentally ill, but manifests a longstanding disorder of character and behavior which is of such severity as to tender the individual incapable of serving adequately in the Navy. The member does not presently require and will not benefit from hospitalization or psychiatric treatment.” 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) (2019). Nonetheless, service connection may be granted if the evidence shows that an acquired psychiatric disorder was incurred or aggravated in service and superimposed on the pre-existing personality disorder. 38 C.F.R. §§ 4.9; 4.125(a), 4.127. However, once again, the STRs do not offer evidence of such an acquired psychiatric disorder. For example, the February 2017 VA examiner concluded in his opinion there is no evidence during the years immediately after separation from active service of the symptoms noted in-service as depressive, such as poor hygiene, apathy and getting into fights, as such symptoms “were a temporarily disabling condition in response to in-service stressors, and the condition ceased once the stressors were gone.” The post-service record does not show psychiatric disorders until May 1995, with diagnoses of major depression with melancholia, rule out major depression with psychotic feature and rule out schizoaffective disorder; passive dependent personality; and psychosocial stressor, recently divorced, severe. Throughout 1995 and 1996, diagnoses overall included major depression and were understood in the context, based on the Veteran’s own detailed reports, of the psychosocial stressors of divorce, child custody and employment issues. There is nothing in the record which offers medical evidence establishing a connection of the Veteran’s current acquired psychiatric disorder to active service. Lastly, psychoses are included as chronic diseases within the meaning of 38 C.F.R. § 3.309 (a) and therefore are eligible for presumptive service connection. For example, the Veteran reported auditory hallucinations in July 1996 and his January 2001 diagnosis included “psychosis.” However, the record offers no evidence of the manifestation of a psychosis to a compensable degree within a year of separation from active service. Additionally, because it was never identified in service or directly after, and putting aside the lack of medical evidence of treatment at that time, it would be otherwise impossible to establish continuity of symptomatology based on the identification of symptoms during, directly after or continuing for a longer period after active service. Consequently, the presumption of service connection for a psychosis as a chronic disease is not available to the Veteran. The Board has carefully considered the Veteran’s August 2017 Board hearing testimony and his September 2012 and November 2016 Statements in Support of Claim. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is usually no reason to doubt his credibility. Nonetheless, the lay evidence of the Veteran must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran has argued in his September 2012 and November 2016 Statements in Support of Claim that he had no psychiatric disorder when he entered the Navy, he then suffered psychiatric symptoms during service and left the Navy with psychiatric disorders. From this, he concludes active service in the United States Navy must have caused his psychiatric disorder(s). As already stated, the Veteran is competent to report what he saw and felt. However, the inferences he has drawn from what he experienced and observed fall outside the realm of his competency. The record does not indicate he possesses the highly specialized education, training and clinical experience to be able to identify the origins, causes and distinctions in pathology relating to his perceptions. As already stated, other than personality disorder assessed very near to separation from active service, the STRs show no reports, complaints, treatment, or diagnoses for a mental disorder. Without clinical evidence of the existence of a disorder or disorders the Veteran believes were present during active service, as well as a causal relationship to the subsequent diagnosed current disorders, what remains is only the suggestion that the claimed disorders are associated and the belief of the Veteran as a lay person that a certain legal conclusion should be reached. The Veteran’s inference of causation is therefore not competent evidence but, rather, conjecture. In his August 2017 Board hearing testimony, the Veteran stated he was diagnosed in-service “with a possible adjustment disorder and depression.” However, the Board notes the STRs do not included these diagnoses. In a June 1989 in-service treatment note, the treatment provider merely noted that the Veteran “appeared” depressed, and in May 1989 another stated in his diagnosis to “rule out” adjustment disorder with depression. The Board emphasizes that to rule out a diagnosis is to eliminate it or exclude it as a serious diagnostic consideration; it is not itself a diagnosis. The Veteran further testified he received mental health treatment approximately every 3 weeks. However, this too is not borne out in the Board’s review of the STRs. The relevant interviews with the Veteran set forth above took place only in the months of May through August 1989. In questioning the Veteran at the hearing, the Veteran’s representative stated that the Veteran’s VA examiner stated his in-service symptoms more resembled an adjustment disorder and after service it was in remission. However, the February 2017 VA examiner, after stating the diagnosis of adjustment disorder is a more accurate diagnosis than the personality disorder diagnosis given at discharge, adds, as already stated above, that such a diagnosis “would not have been continued following cessation of the stressor, which was the demands of military service. Although the Veteran testified that no physician has said that any of the Veteran’s mental disorders have ever been in remission, the February 2017 VA examiner if fact added to his above statement, “Furthermore, there is no evidence during the years immediately after discharge of the symptoms noted in-service as depressive, such as poor hygiene, apathy, and getting into fights. Thus, the in-service symptoms were a temporarily disabling condition in response to in-service stressors, and the condition ceased once the stressors were gone” (emphasis added). Although the Veteran testified that he had experienced a hallucination of seeing a land mass while on board his ship and for that reason he was sent to see mental health treatment providers, the STRs do not contain notes by a treatment provider to that effect. The reasons he was sent to them are set forth in detail as being related to poor performance and unacceptable hygiene. There are other instances of assertions by the Veteran which are contradicted by the evidence of record. For example, the Veteran testified regarding post-service treatment that “he was hospitalized for two weeks “and the psychiatrist at the time told me that I’d be ready to go home. It was a Friday. I told him I wasn’t ready to go home, and it was the following Monday morning I was back in there for another week.” This appears from the record to be in July 1996, but the treatment provider’s notes state the Veteran, three days after hospitalization and after medications helped him to become calmer, demanded his immediate release. Based on the inconsistencies of the above testimony with the record, the Board can only conclude that the Veteran’s statements are, at the very least, problematic in terms of probative value. Returning briefly to the Veteran’s broadest, but most essential, assertion, that he had no disorder before service in the Navy but had one or more when leaving the Navy, the evidence of record shows no psychiatric treatment until 1995. A reasonable and plausible connection cannot be established between such an assertion by the Veteran and the existence and severity of a disorder which would otherwise impel a reasonable person to seek treatment whether in service, directly after or in the years following. Based on this foundation, the Board finds the Veteran’s lay evidence overall not credible. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection, direct or presumptive. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.