Citation Nr: 21023989 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 18-24 874 DATE: April 21, 2021 ORDER New and material evidence having been received, the application to reopen the claim of entitlement to service connection for an acquired psychiatric disorder is granted. Service connection for schizoaffective disorder is denied. FINDINGS OF FACT 1. A final February 2011 Board decision denied service connection for an acquired psychiatric disorder; evidence received since that time raises a reasonable possibility of substantiating the claim. 2. The Veteran’s current psychiatric disability did not clearly and unmistakably preexist service; did not onset within one year of separation; and is not etiologically related to service, including in-service psychiatric symptoms and diagnoses. CONCLUSIONS OF LAW 1. Evidence received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder is new and material and the claim is reopened. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. § 3.156. 2. The criteria for service connection for schizoaffective disorder have not been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from December 1967 to May 1968. He testified during a February 2021 virtual hearing. A transcript of this proceeding has been associated with the record. Later that month, the Veteran executed a new VA Form 21-22a identifying the above agent as his power of attorney. This new appointment has been updated throughout VA systems. Briefly, the Veteran submitted new claims in April 2020 and October 2020 which have not yet been adjudicated by the Regional Office (RO). Given the date of the claims, these matters are governed by the modernized system, known by the Board as the AMA. 38 C.F.R. §§ 3.2400, 19.2(a). Accordingly, the Board is prevented from referring these matters to the RO for action at this time. Rather, these outstanding claims are simply noted here, for the parties’ benefit. New and Material Evidence The Veteran is seeking to reopen a service connection claim for an acquired psychiatric disorder. VA may reopen a claim for service connection which has been previously and finally disallowed when new and material evidence has been presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996). In this regard, “new evidence” means existing evidence not previously submitted to VA. “Material evidence” means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Taken in combination, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence may be sufficient to reopen a claim if it can contribute to a more complete picture of the circumstances surrounding the origin of a claimant’s injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998); Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). Thus, the Board must first determine whether new and material evidence has been submitted under 38 C.F.R. § 3.156(a) to have a claim reopened under 38 U.S.C. § 5108. Elkins v. West, 12 Vet. App. 209 (1999). Then the Board may proceed to evaluate the merits of the claim after ensuring that VA’s duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). To determine whether new and material evidence has been submitted, it is necessary to consider all evidence added to the record since the last time the claim was denied on any basis in conjunction with the evidence already of record. Here, the Veteran has been pursuing service connection for the claimed psychiatric disorder for the better part of five decades. In pertinent part, service connection was denied in a February 2011 Board decision. As the Veteran did not appeal this decision to the United States Court of Appeals for Veterans Claims (CAVC) within 120 days of its issuance or request its reconsideration, the February 2011 Board decision is final. 38 U.S.C. § 7104; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Veteran requested to reopen the claim in September 2014. Now, the Board must determine whether new and material evidence has been submitted since the final February 2011 decision sufficient for the claim to be reopened. January 2015, February 2017, and January 2020 VA and private treatment letters which speak to a possible nexus between the Veteran’s current psychiatric disability and his military service. These opinions speak directly to an unestablished fact necessary to substantiate the claim (i.e., the nexus element of direct service connection), and thus constitute material evidence. Accordingly, new and material evidence has been received following the prior final denial of this claim. Thus, the application to reopen the service connection claim is hereby granted. Service Connection Upon the reopening of this claim, the Board will now address its merits. When the Veteran first solicited service connection for the claimed disorder, the record was in controversy as to whether a psychiatric condition preexisted service. 8 U.S.C. § 1111; 38 C.F.R. § 3.304(b); VAOPGCPREC 3-2003 (July 16, 2003); see, e.g., July 1972 lay statement (reporting that the Veteran had “mental problems” when he entered service and which were aggravated thereby); June 1978 lay statement (reporting that a mental illness onset in service and had persisted since that time); November 1985 father’s statement (reporting that the Veteran had some “emotional problems” as a child, but no psychiatric or psychotic illnesses). Earlier medical records were also unclear on this point. See, e.g., VA examinations dated October 1969 (diagnosing preexisting psychophysiological gastrointestinal reaction, chronic and moderate, and preexisting personality trait, disturbance, passive-aggressive personality); November 1988 (noting childhood symptoms but that the Veteran first “came to the attention of a psychiatrist” during service); August 1994 (noting that there were “signs and symptoms suggestive of a chronic illness” prior to service, which then “exacerbated” his symptoms). Subsequently, multiple medical experts have concluded that the Veteran’s current psychiatric disorder did not clearly and unmistakably preexist service. VAOPGCPREC 3-2003 (July 16, 2003); see also VA examinations dated December 2000 (concluding that the Veteran’s current schizoaffective disorder clearly and unmistakably did not preexist service); April 2009 independent medical opinion (concluding that it was not clear and unmistakable that the Veteran’s current schizoaffective disorder preexisted service; while he showed psychiatric symptoms prior to and during service, there is “no evidence” that he suffered from a primary psychotic disorder until 1977); see also VA examination dated March 2015 (diagnosing the Veteran with a current schizoaffective disorder, but noting that the Veteran was diagnosed with a personality disorder during service, which typically represent “long-standing, pervasive characterological issues with origins in childhood, thus pre-dating military service). As such, the Board has repeatedly held that the Veteran’s currently diagnosed psychiatric disability did not clearly and unmistakably preexist service. See Board decisions dated May 2002, February 2006, and February 2011. The Veteran has not argued otherwise during the current period on appeal, or presented evidence in support of such a finding. Accordingly, the Board’s prior findings will not be disturbed in this respect; rather, it is maintained that the Veteran’s current psychiatric disability did not clearly and unmistakably preexist service. Rather, the Veteran is pursuing direct service connection at this time. The Board will limit its analysis accordingly. Generally, service connection may be granted directly as a result of disease or injury incurred in service based on nexus using a three-element test: (1) The existence of a current 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 by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Presumptive service connection is available: (i) Where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury is shown at a later date unless clearly attributable to an intercurrent cause under 38 C.F.R. § 3.309(a); or (ii) where a condition is noted in service but is not chronic or where chronicity may be legitimately question and there are continuity of symptomatology but only for specific chronic diseases listed in 38 C.F.R. § 3.309(a); or (iii) with certain chronic diseases listed in 38 C.F.R. §§ 3.307, 3.309(a) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. Psychoses qualifies as one such disorder. Here, the Veteran has been diagnosed with multiple psychiatric disorders throughout his lifetime. However, medical evidence obtained during the period on appeal routinely diagnoses the Veteran with current schizoaffective disorder. See, e.g., January 2015 private evaluation (“His diagnosis is schizoaffective disorder, depressed; panic disorder without or phobia; social phobia; and generalized anxiety disorder”); March 2015 VA opinion (diagnosing current schizoaffective disorder); February 2017 private treatment letter (diagnosing schizoaffective disorder or “other illnesses of the spectrum”); January 2020 VA treatment letter (diagnosing schizoaffective disorder and unspecified anxiety disorder with OCD features). Critically, the Veteran was not diagnosed with psychoses at any time during the period on appeal, such that presumptive service connection does not apply. Rather, the first element of direct service connection—a current disability, classified hereinafter as schizoaffective disorder—has been met. The second element of direct service connection is just as easily met in this case. As previously noted by the Board, Service treatment records indicate that the Veteran reported to sick call over 20 times in January and February 1968 with a variety of complaints. On [January] 24, 1968, the Veteran was admitted to the U. S. Army Hospital at Fort Jackson with multiple complaints. On several occasions, the Veteran reported he was well aware that most of his complaints were psychic in origin and that he had problems with nervousness for many years. He readily admitted a poor tolerance for stressful situations. During the hospitalization, the Veteran underwent several consultations, including psychiatric. The physician also spoke with the Veteran’s parents, who stated that they had much difficulty with their son’s nervousness in the past and were not surprised to hear of his adjustment difficulties. See February 2011 Board decision, p. 8. Following the Veteran’s hospitalization, a psychiatric evaluation was provided in April 1968. At that time, he was diagnosed with “passive-aggressive personality, chronic, severe; manifested by immaturity, passive-aggressive behavior, somatization, poor tolerance under stress, mild anxiety.” The source of his stress was identified as “routine military service,” with a predisposition for passive-aggressive personality adjustment. Ultimately, the “chronicity and severity” of the Veteran’s personality disturbances rendered him a “poor candidate for training as a soldier.” Contemporaneous field officer reports also document the Veteran’s history of misconduct during service. In a Discharge for Unsuitability memorandum, it was reported that the Veteran had “been a constant disciplinary problem” to his superior officers: [He] has been on sick call constantly, and has complained of various ailments . . . [he] has had a thorough medical check with results stating he is fit for full duty. [He] has been involved in several fights while in my unit and seems unable to get along with any of his fellow trainees. [He] made general threatening remarks as to how he is going to kill someone while in my unit. [He] seems to have problems with any personnel with whom he comes in contact. [He] has been recycled on two different occasions while in my unit and has not completed training in either case. [He] was sent to Special Training Company for motivation with no success. The Veteran’s April 1968 exit examination diagnoses him with passive aggressive personality, chronic and severe. He was ultimately discharged for unsuitability. Thus, it is apparent that the Veteran demonstrated psychiatric symptoms during service, which were routinely attributed to a personality disorder. Accordingly, the second element of direct service connection—an in-service incurrence—has also been met. The final question remains whether there is a nexus between the Veteran’s in-service symptoms and diagnoses and his current disability. A significant body of evidence has been generated in the more than 50 years the Veteran has been pursuing service connection. Although the Board is obligated to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claim. A detailed overview of the evidence was provided in the Board’s February 2011 decision, as follows: [T]he Veteran underwent a VA psychiatric examination in September 1969. His claims folder was not available for review and the history was obtained from the Veteran. Diagnoses were as follows: 1) psychophysiological gastrointestinal reaction, chronic, moderate, existing prior to service; and 2) personality trait, disturbance, passive-aggressive personality, pre-existing service, manifested by passive measures, stubbornness, pouting, temper tantrums, and aggressiveness under minor stress. The Veteran underwent a VA psychological intake interview on March 27, 1972, and was subsequently hospitalized. The diagnostic impression was chronic undifferentiated schizophrenia, with emotional confusion, tension, somatization, and paranoid trends. The hospital summary indicated that the Veteran had schizoid, obsessive and somatic symptomatology but that evidence of psychosis or organicity was not manifest. The discharge diagnosis was schizoid personality. In June 1974, the Veteran was admitted to the University of Pittsburgh Western Psychiatric Institute and Clinic. He had been followed as an outpatient and returned complaining of depression. The Veteran was very interested in what was written in his chart and he thought his diagnosis was “schizophrenia, paranoid, delusions of grandeur.” The impression was as follows: Inadequate personality with depressive mood and thought content and possible mood swings, but complains of neurovegetative accompaniments of depression. Possibly having to manipulate the system to get V. A. or S. S. pension. Records show that the Veteran was discharged in July 1974 and was subsequently referred to the day hospital. A discharge summary reflected a diagnosis of borderline personality. The statement of admission to the day hospital indicated that the Veteran had a rather extensive psychiatric history and, according to his father, had problems since about age 3. It was noted the Veteran was a management problem since age 5 when he set fires, and that this behavior continued into his school years when he was frequently truant and involved in fights. Since then, the Veteran has disputed these statements as inaccurate and incorrect. A treatment summary also indicated the Veteran received treatment at Western Psychiatric Institute from approximately January 1974 to June 1975. In May 1975, the Veteran underwent another VA psychiatric evaluation. The diagnosis was borderline personality disorder. The examiner noted there were some features that suggested this was a latent type of schizophrenia. A VA interim summary dated in January 1977 indicated a diagnosis of schizophrenia, chronic, undifferentiated type with confusion, tension, somatization and paranoid trends. The summary also noted the Veteran’s history and his continued complaints of depression, “mixed-up” feelings, fear of losing control, and the attitude of his parents. The Veteran was noted to be the same as he was 4 years previously. In June 1979, the Veteran was evaluated by Dr. R. Shoemaker in connection with his application for Social Security benefits. The Veteran complained of social isolation, and the examiner was struck by the Veteran’s suspiciousness throughout the interview. The diagnosis was schizophrenic reaction, chronic, undifferentiated type. In December 1980, a VA Psychiatry Service Chief submitted a memorandum on the Veteran’s behalf which noted that the Veteran was recently hospitalized for manic depressive illness, mixed type. Based on his review of available records, the psychiatrist stated that it was possible that the Veteran’s depression, somatic complaints and inappropriate behavior exhibited during service may have been an expression of his illness. In June 1982, the Veteran was again evaluated by Dr. Shoemaker. Dr. Shoemaker stated that he began treating the Veteran as a private patient in April 1982 at the request of the Veteran’s father, and saw him once or twice a week in extended psychotherapeutic interviews. The Veteran showed a mixture of schizophrenic and manic symptoms. In tracing the Veteran’s history, it was Dr. Shoemaker’s opinion that the Veteran became actively psychotic while in service and that his mental illness was not recognized. Dr. Shoemaker further opined that the Veteran’s military discharge should have been a medical discharge on a psychiatric basis. The diagnosis was schizo-affective disorder, chronic, severe. It was Dr. Shoemaker’s belief that the Veteran’s chronic mental illness was service-connected. A February 1985 report from Dr. E. L. Youngue indicates he examined the Veteran in August 1984. The Veteran presented to Dr. Youngue with numerous service and VA records, and was completely preoccupied with his VA claim. The Veteran reported numerous somatic and emotional complaints. The Axis I diagnosis was schizophrenic reaction paranoid type. In reviewing the records, it was Dr. Youngue’s opinion that this had been the diagnosis all along. The Axis II diagnosis was severe depression with anxiety and odd behavior with clear personality difficulty associated with the Axis I diagnosis. Dr. Youngue further opined that the Veteran’s behavior during service demonstrated the presence of a psychosis. An April 1988 VA mental hygiene clinic note reflected a diagnosis of schizoaffective disorder and mixed personality disorder, with the examiner noting that he was unable to make a retrospective diagnosis regarding the Veteran’s condition during service; and that given the Veteran’s personal investment in changing his diagnosis, it was impossible to resolve this issue. See February 2011 Board decision, pgs. 8-11. The Veteran also underwent VA examination in November 1988, at which time he was assigned an Axis I diagnosis of schizo-affective disorder, depressed, and an Axis II diagnosis of mixed personality disorder, passive aggressive and borderline features. The examiner noted that the Veteran was “significantly preoccupied” with his diagnosis and ongoing claim for service connection. Although a detailed medical history was provided, including of the Veteran’s in-service symptoms, a nexus opinion was not provided at that time. As per the Board’s February 2011 decision: A July 1993 statement from the Veteran’s father, who is also a physician, indicated that prior to service the Veteran was a healthy young adolescent. He stated that during service the Veteran suffered from various illnesses and emotional problems, and that due to stress, had difficulty adjusting to military life. After discharge, the Veteran’s father provided him with tranquilizers and sedatives. It was the father’s opinion that any current and past psychiatric problems resulted from the Veteran’s military experience. A January 1994 progress note by a VA psychiatrist, who indicated that a review of the Veteran’s military and medical history was conducted, concluded that the Veteran’s schizophrenia “squarely and unequivocally dates from his military tour of duty.” An undated letter, which appeared to be written by the same examiner, notes a similar opinion. The Veteran underwent a VA psychiatric examination in August 1994. The examination was conducted by two physicians who were present simultaneously. The Axis I diagnoses were cyclothymia, rule out schizophrenia and rule out impulse control disorder. The axis II diagnosis was schizotypal personality disorder. The general impression was that the Veteran suffered from a schizophrenic continuum disorder. Because of the possibility that the Veteran may have had psychotic episodes in the past that he may be minimizing or denying, the examiners were unable to completely rule out the possibility that he had schizophrenia. Regarding whether he had psychiatric symptoms prior to service, the examiners indicated the following: Clearly, his time in the service exacerbated his symptoms, but it also seems there were signs and symptoms suggestive of a chronic illness prior to his entering the service. Whether he was treated unfairly or not in the service is unclear, but give[n] the environment of basic training, it was clearly too much for him to handle and it is not surprising that he had a breakdown. This seems to be consistent with his father’s impression reported back in the late 1960’s. In a September 1995 memorandum that followed a review of the claims folder, the Director of the VA Mental Health and Behavioral Sciences Programs indicated that the Veteran had a lifelong personality disorder with intermittent psychosis which was first documented in January 1977 but is not present now. The psychosis did not pre-exist service but a functional disability clearly existed prior to service. The records support a clear manifestation of his personality disorder when faced with the normal expectations of military service but do not suggest the presence (or significant aggravation) of an Axis I diagnosis during service. The memorandum further noted that the issue of diagnosis rested “on various interpretations of the apparent progression of the Veteran’s maladaptive personality traits from childhood and early adulthood into a clear personality disorder... by the time [the Veteran] was in the service, punctuated by an intermittent psychosis... first documented 1/3/77 and intermittently again at least up through 1988.” In December 2000, the Veteran underwent a VA examination by a board of two psychiatrists. The Veteran’s claims folder was reviewed prior to the examination. It was noted that both examiners have at least 8 years experience since residency, both are licensed physicians and board certified psychiatrists, and both have served at least most of their careers in the diagnosis and treatment of psychotic disorders. Both have academic appointments to the University of Pittsburgh Department of Psychiatry, and both have authored or co-authored articles in professional journals dealing with diagnosis and treatment of psychotic disorders. The examiners were requested to provide answers to the following questions: A) Does the Veteran currently have an acquired psychiatric disorder and, if so, what is its correct diagnosis; B) If the Veteran currently has a chronic acquired psychiatric disorder, as distinguished from a personality disorder, did the chronic acquired psychiatric disorder clearly and unmistakably pre-exist service; C) If the answer to question B is in the affirmative, did such disorder increase in severity during service; D) If the answer to question A is affirmative, but the answer to B is negative, did the disorder develop during service; and E) Does the evidence of record reveal that a psychosis initially became manifested in the first post-service year. The Veteran’s 30 plus-years psychiatric history was thoroughly summarized and set forth in detail. Following the examination, the diagnoses included the following: AXIS I: Schizoaffective disorder. This includes and subsumes previous diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder and cyclothymia. This is manifested by intermittent psychosis, prominent difficulties with depression, prominent irritability. Although diagnoses have varied, the presenting symptoms have been reasonably consistent over the past 23 years and are best accounted for by this inclusive diagnosis. Given the fact that he was assessed repeatedly in the years immediately before and after this diagnosis, it can be stated with certainty that this disorder, his only chronic acquired psychiatric disorder, had an onset in 1977 when he was 28 years old. AXIS II: Personality disorder with schizotypal, borderline, passive aggressive, paranoid features. This preceded his enlistment in active duty by at least four years. In response to the specific questions posed, the examiners provided the following opinions: A) The Veteran does currently have a chronic acquired psychiatric disorder. The diagnosis is schizoaffective disorder. B) The chronic acquired psychiatric disorder clearly and unmistakably did not pre-exist service. C) The chronic psychiatric disorder was not exacerbated by his being in the service as it did not pre-exist the service, nor is there any indication it was present during the time he spent in the service. D) The current chronic acquired psychiatric disorder did not develop during service, but in fact several years later. E) The psychosis/chronic acquired psychiatric disorder did not initially become manifest in the first post-service year. The examiners further indicated that based on the current information, they did not believe it was possible to come to any other conclusion. They noted that considerable resources have been expended in addressing the Veteran’s claim for service connection. For the benefit of the government and the Veteran, they urged that this question not be addressed through further evaluation. Because the Veteran alluded to possible violence as a result of the government’s failing to pay him disability, they informed the Veteran and noted their conclusion that he is capable of distinguishing right from wrong and further is capable of conducting himself accordingly. Following this opinion, additional clinical records have been associated with the claims folder and diagnoses have included schizophrenia. In a Memorandum Decision by the Court, it was noted that the December 2000 opinion did not discuss or reconcile the 1980, 1982, and 1985 opinions that suggest acquired psychiatric disease had its clinical onset in service and was misdiagnosed as a personality disorder. It was suggested that VA may wish to consider referral for an opinion by an independent medical expert. Following the Court’s February 2008 Memorandum Decision, the Board sought an independent expert medical opinion to address the question of etiology of the Veteran’s diagnosed psychiatric disability. [In April 2009, the] expert reviewed the Veteran’s claims file and treatment records, and the medical opinions of record. The expert indicated that the cumulative data suggest that the Veteran suffered from both chronic personal pathology and a primary psychotic disorder that emerged in his late twenties. The expert also noted that there is evidence, from a review of the record, which suggests that the Veteran displayed psychiatric symptoms and functional impairment prior to and during his time in service. The Veteran’s symptoms were thought to be due to his personality pathology, and no clinician had determined that the Veteran suffered from a primary psychotic disorder until 1977. The expert concluded that many errors can be made in reviewing a Veteran’s history and trying to diagnose a Veteran’s illness at a given time in the past. The expert reconciled the 1980, 1982, and 1985 opinions by revealing that those opinions all must assume that the clinicians who actually evaluated the Veteran during and after his time in service did not complete an adequate evaluation and/or misinterpreted the Veteran’s presenting symptoms and history. The expert opined that those types of assumptions are fraught with error. A Veteran’s subjective telling of his history invariably changes over time, and the Veteran’s evolving presentation of his history was obviously shaded by his ongoing attempts to obtain VA benefits. Moreover, the Veteran’s father’s telling of the history is also documented as having changed across time; and evaluations of each subsequent clinician will be influenced by the subjective history presented. In essence, the expert opined that the most reliable evidence is the documented mental status and diagnoses made by clinicians who evaluated the Veteran at each pertinent time in question. The expert indicated that the Veteran was evaluated by multiple clinicians in multiple settings who found that he only met criteria for a personality disorder, until the emergence of acute psychosis in 1977. While acknowledging that a given patient can be misdiagnosed, the expert indicated that there was nothing in the documentation that suggested that the quality of the Veteran’s past evaluations was so poor as to contradict the provided diagnoses. Here, the expert agreed with the evaluation that was completed by the two psychiatrists in December 2000. See February 2011 Board decision, pgs. 11-16. At this time, the Board affirms that its February 2011 history was a full and accurate representation of the available evidence at that time. Since then, additional medical evidence has been obtained. Notably, a January 2015 private assessment concludes that the Veteran was misdiagnosed during service, and should have been discharged with a diagnosis of either schizoaffective disorder, bipolar type, or major affective disorder with psychotic features. In doing so, the evaluator noted the Veteran’s belief that he was misdiagnosed during service, and his testimony of chronic symptoms since that time. Following separation, the Veteran was hospitalized in 1972 and 1980 for anxiety, depression, and schizophrenia. Currently, he presented with schizoaffective disorder, depressed; panic disorder without or phobia; social phobia; and generalized anxiety disorder. The Veteran’s previous evaluations “appear to agree” that he became “gravely disabled” following service, but did not definitively indicate a nexus thereto. However, the evaluator concluded that there was “every reason to believe” that the Veteran’s schizoaffective disorder onset during service and was exacerbated thereby, as his later diagnosis of major affective disorder “give[s] one cause” to understand his in-service symptoms as part and parcel of his later diagnosis. Thus, there was “every indication” that the Veteran became disabled during service, as evidenced by his medical history, symptoms, and related social impairment. In offering this conclusion, the evaluator noted that the in-service diagnosis of a personality disorder was “reportedly” made by a non-behavioral military medic, which “can only cast great doubt” as to the accuracy of the diagnosis. Moreover, schizoaffective disorder was not particularly understood in the 1960s, and the Veteran was not assessed by a government psychiatrist during service. In contrast, a March 2015 VA examiner noted that the Veteran was given a “general under honorable conditions administrative discharge for unsuitability.” An April 1968 report summarizes the Veteran’s extensive difficulties in adapting to military service, with an accompanying diagnosis of a personality disorder (passive-aggressive). There was no indication in this evaluation or any of the Veteran’s other service treatment records of symptoms consistent with a mood disorder, anxiety disorder, or thought disorder (such as depression, panic disorder, schizoaffective disorder, or schizophrenia). He was never diagnosed with a primary mood, anxiety, or thought disorder during service. Thus, the contention that his service-connected difficulties were manifestations or triggers of later diagnosed psychiatric disorder is “speculative only,” and not supported by the evidence. Therefore, it was found that the Veteran’s current psychiatric diagnosis of schizoaffective disorder is unrelated to (and not aggravated by) military service. Further, personality disorders, by their nature, represent long-standing, pervasive characterological issues with origins in childhood, thus pre-dating service. Subsequently, a February 2017 private treatment letter confirms the Veteran’s current diagnosis of schizoaffective disorder. The evaluator’s review of the record indicates that the Veteran has presented with this diagnosis for at least 15 years, but likely had the disorder for “many years” prior to his solicitation of VA treatment. Similarly, a January 2020 VA treatment letter diagnoses the Veteran with schizoaffective disorder and unspecified anxiety disorder with OCD features. The Veteran “reports a long history of affective symptoms dating back to his time in the military.” In effect, the Veteran now argues that his appeal should be granted upon the probative value of the February 2015 private positive opinion. In doing so, he argues that the March 2015 VA negative opinion is inadequate for several reasons, including the examiner’s disregard of precedent which holds that “evidence of treatment for particular symptoms is not required” and that service connection can be established even absent an in-service diagnosis, in addition to her purported failure to address the continuity of the Veteran’s symptoms. See, e.g., March 2021 representative’s memorandum. The Board disagrees with the Veteran’s assessment as to the adequacy of the March 2015 VA opinion. The probative value of a medical opinion is derived from the “factually accurate, fully articulated, sound reasoning for the conclusion.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008); Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Such reasoning is apparent in the March 2015 opinion, which is based upon the examiner’s documented contemplation of all conflicting evidence of record—including the Veteran’s service records, prior VA examinations, and the positive February 2015 opinion. Importantly, there is no indication that the March 2015 examiner was not fully aware of the Veteran’s past medical history or misstated any relevant fact in providing her nexus opinion. Rather, her contemporaneous and thorough review of the evidence supported her conclusion that the Veteran’s in-service symptoms were the result of a separate and distinct psychiatric disability than that current diagnosed. See also 38 C.F.R. §§ 3.303(c), 4.9 (prohibiting an award of service connection for personality disorders). Insofar as the Veteran argues that the March 2015 examiner disregarded relevant legal precedent, the Board again disagrees. Critically, the VA opinion is neither based upon the absence of continuous treatment since service nor disregards the Veteran’s reports of continuous symptoms. Savage v. Gober, 10 Vet. App. 488, 496 (1997); see also Wilson v. Derwinski, 2 Vet. App. 16,19 (1991) (noting that the “regulation requires continuity of symptomatology, not continuity of treatment”). Rather, the examiner explicitly accounts for the Veteran’s in-service symptoms in finding that they are inconsistent with his current disability, and are instead attributed to a diagnosis which is no longer shown. Additionally, the Veteran’s accusation that the examiner “was operating under the false pretense that a condition had to be diagnosed during service for it to be related to military service” grossly misconstrues the examiner’s findings. March 2021 representative’s memorandum, p. 8. Again, the examiner did not deny a nexus upon her conclusion that the Veteran was not diagnosed with an in-service psychiatric disability, but rather that the in-service symptoms and diagnoses were inconsistent with the Veteran’s present condition. See March 2015 VA examination (acknowledging the Veteran’s in-service symptoms and diagnoses but concluding the contention “that his documented in-service difficulties were manifestations or triggers of later diagnosed psychiatric disorders is speculative only and is not supported by the evidence”). Thus, there is no basis to conclude that the March 2015 opinion was based upon an inaccurate or incomplete factual premise or the misapplication of VA regulations governing the award of service connection. Moreover, the February 2015 private opinion is certainly no more probative than the subsequent VA examination. First, the private opinion is at least partly based upon an inaccurate factual premise, as the evaluator stated that there was “no indication that the Veteran was disabled prior to the military.” This is simply untrue, as the evidentiary inconsistencies regarding a preexisting disability have been at issue since the Veteran first filed a VA claim. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding a medical opinion based upon an incomplete or inaccurate factual premise is not probative). Even more problematic is the examiner’s unyielding reliance on the Veteran’s testimony in this case; indeed, it appears that the letter was crafted around the Veteran’s theory of entitlement as opposed to the objective medical evidence. However, the Veteran lacks the expertise to offer a competent opinion as to complex medical matters, to include the distinction between his in-service and subsequent symptoms. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Further, his testimony over the span of five decades contains multiple inconsistencies, such that his statements are not more credible than the objective medical evidence. Miller v. Wilkie, 32 Vet. App. 249 (2020); see, e.g., August 1972 lay statement (indicating that his disability preexisted service), but see April 1979 lay statement (indicating that his disability did not preexist service); January 1998 lay statement (containing the Veteran’s request to alter his records to reflect his self-made diagnoses). However, the greatest deficiency of the February 2015 private opinion is its speculative nature. In sum, the evaluator argues that the Veteran was misdiagnosed during service, without reference to any objective supporting evidence. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor’s statement framed in terms such as “could have been” is speculative and not probative). Instead, the private evaluator undermines the credentials of the diagnosing military medic and notes that an older version of the Diagnostic and Statistical Manual (DSM) was in effect during the Veteran’s period of service. While these statements may provide some context as to the in-service diagnosis, it does not plausibly establish that the diagnosis is inherently uncredible. At most, the disparity here represents conflicting medical opinions, without establishing that the in-service diagnoses so significantly contradicted current medical standards as to render the diagnosis unreliable. Indeed, the most probative opinion of record remains the April 2009 independent medical opinion upon which this appeal was previously denied. Therein, the examiner clearly speaks to the type of error later made by the February 2015 examiner: Many errors can be made in reviewing a patient’s history and trying to diagnose the patient’s illness at a given time in the past . . . [assuming that prior examiners did not conduct an adequate evaluation or misinterpreted the Veteran’s symptoms is] fraught with error. A patient’s subjective telling of his history invariably changes over time. This patient’s evolving presentation of his history was obviously shaded by his ongoing attempts to obtain service-connection. The father’s telling of the history is also documented as having changed across time. The evaluation of each subsequent clinician will be influenced by the subjective history that the patient and his family present . . . [T[he most reliable evidence is the documented mental status and diagnoses made by those clinicians who evaluated the patient at each pertinent time in question. See April 2009 independent medical opinion, pgs. 2-3. The Board finds this argument, offered by a medical expert and with clear consideration as to the nature of this case, to be persuasive on this point. Thus, the February 2015 opinion as to an in-service misdiagnosis is not found to be probative. More generally, the April 2009 opinion is highly probative in its own right. Here, the medical expert offered clear medical diagnoses in accordance with the DSM; concluded that the Veteran’s current diagnoses did not preexist service, as based upon the evidence of record; and clearly distinguished between the Veteran’s current and former conditions. Nieves-Rodriguez, 22 Vet. App. at 302-04; Prejean, 13 Vet. App. at 448-49. The examiner also accounted for the numerous medical incongruencies in the record, and offered a compelling argument as to which objective medical evidence is the most credible in this case. Importantly, no subsequent opinion offered any specific argument as to why the April 2009 opinion is not probative in this instance. In sum, the Veteran did not demonstrate a preexisting psychiatric disorder. Although his symptoms onset during service, they are most reliably attributable to a diagnosis of personality disorder, for which service connection is prohibited. Several years following his military separation, the Veteran was diagnosed for a separate and distinct condition (specifically, schizoaffective disorder). Those symptoms have persisted since that time, but are unrelated to service. Thus, the preponderance of the evidence is against the claim such that the benefit-of-the-doubt rule is not applicable, and the appeal is thus denied. In offering this finding, the Board has considered the Veteran’s prolonged and good faith belief that service connection is warranted in this case. To be clear, the Board has not found that the Veteran did not experience in-service psychiatric symptoms or stressors; only that his symptoms are due to a different condition than currently demonstrated. However, it is also apparent that the Veteran had a difficult military experience. The Board is grateful for his service, and regrets that a more favorable outcome cannot be offered at this time. [CONTINUED ON NEXT PAGE] Of final note, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kovarovic, 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.