Citation Nr: 21025794 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 17-50 719 DATE: April 29, 2021 ORDER Service connection for hypertension is granted. Service connection for major depressive disorder (MDD) is denied. Service connection for alcohol use disorder is denied. Service connection for obstructive sleep apnea (OSA) as secondary to a psychiatric disability is denied. REMANDED Entitlement to service connection for lung nodules is remanded. Entitlement to service connection for kidney stones is remanded. FINDINGS OF FACT 1. The Veteran’s exposure to herbicide agents during service in the Republic of Vietnam during the Vietnam era is presumed. 2. The Veteran’s medical evidence confirms a current diagnosis of hypertension. 3. Epidemiologic evidence supports positive association between hypertension and herbicide agent exposure. 4. The evidence is in equipoise as to whether the Veteran’s currently diagnosed hypertension is related to his conceded exposure to herbicide agents during Vietnam service. 5. A preponderance of the evidence is against a finding that the Veteran has been diagnosed with a depressive disorder under the DSM-IV or DSM-5, to include MDD, during the appellate period. 6. Service connection for alcohol use disorder is precluded. 7. Service connection has not been awarded for a psychiatric disability; thus, service connection for OSA, claimed as secondary to a psychiatric disorder cannot be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. 2. The criteria for service connection for a depressive disorder, to include major depressive disorder, have not been met. 38 U.S.C. §§ 105(a), 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.125. 3. Service connection on a primary basis for alcohol use disorder is precluded by law. 38 U.S.C. §§ 105(a), 1110, 5107; 38 C.F.R. §§ 3.1(m), 3.301, 3.303. 4. The criteria for service connection for OSA on a secondary basis have not been met. 38 U.S.C. §§ 105(a), 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1967 to April 1969, including in the Republic of Vietnam. He was awarded a Purple Heart and Combat Infantryman Badge for his service. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from September 2013 and October 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). As a procedural matter, these claims were previously before the Board in April 2019. The Board’s prior remand directives have been substantially completed, and the Board will proceed to adjudicate these claims. Additionally, the Veteran’s attorney requested that the Board wait 90 days before adjudicating the claims in August 2020 and again in November 2020. In January 2021, the Veteran’s attorney submitted a brief and supporting evidence and argument and noted it was his final submission. The Veteran’s attorney waived any additional time to send in more argument or evidence, and requested the claims be sent to the Board for adjudication. Although the Board did not respond to these requests, as of the date of this decision, 90 days has passed since the most recent request for a 90-day extension. The Veteran’s attorney has submitted argument and evidence and waived any additional time that he previously requested. The Veteran’s attorney also waived initial consideration by the agency of original jurisdiction of any VA generated evidence that was associated with the claims file after the most recent July 2020 supplemental statement of the case. Therefore, the Board will honor his request and proceed to adjudicate the claims herein.   Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Absent a current disability, there cannot be a valid service connection claim. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Hypertension is considered a “chronic” disease under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on “chronic” symptoms in service and “continuous” symptoms since service must be considered in reviewing the instant claim. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic diseases in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the ‘chronic’ disease became manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. However, MDD or other depressive disorders without evidence of psychosis, alcohol use disorder, and obstructive sleep apnea are not considered “chronic” diseases under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on “chronic” symptoms in service and “continuous” symptoms since service is not for application for these claims. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran who “served in the Republic of Vietnam” between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to an herbicide agent such as “Agent Orange.” 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). VA laws and regulations provide that if a veteran was exposed to herbicide agents during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.309(e) lists the diseases covered by these regulations; however, the listed diseases include neither hypertension nor chronic kidney disease. Therefore, presumptive service connection under these regulatory provisions is not for application. A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Board must determine, on a case by case basis, whether a veteran’s particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider considers such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (quoting 38 U.S.C. § 5107(b)). 1. Service connection for hypertension is granted. As an initial matter, the Veteran has been diagnosed with hypertension since 2001. See November 2019 VA examination. As noted in the introduction, the Veteran served within the Republic of Vietnam during the Vietnam War. Thus, herbicide agent exposure has been conceded. The Secretary of VA has determined that there is no positive association between exposure to herbicide agents and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32, 395-32, 407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21, 260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). Hypertension is not one of the diseases listed for presumptive service connection under 38 C.F.R. § 3.309(e). However, the National Academies of Sciences, Engineering, and Medicine, on November 15, 2018, moved hypertension to the category of “sufficient” evidence of an association from its previous classification in the “limited or suggestive” category,” indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to herbicide agents, including Agent Orange. See National Academy of Science (NAS) November 2018 update report titled, Veterans and Agent Orange Update 11 (2018). The Board finds the study provided by the NAS, which is made up of experts in the given field of science, is probative evidence that is relevant here. Based on this recent scientific evidence, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s hypertension is etiologically related to his exposure to herbicide agents while serving in Vietnam. As such, resolving reasonable doubt in the Veteran’s favor, the Board finds that all elements of service connection for hypertension are met, and the appeal will be granted. The grant of service connection herein on a direct basis renders moot any alternative theory of entitlement. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.303(d). 2. Entitlement to service connection for a depressive disorder, to include MDD, is denied. The Veteran contends he has a psychiatric disability, specifically a depressive disorder, and that it is related to or had onset during service. Specifically, the Veteran contends that he has a currently diagnosed depressive disorder resulting from being wounded in combat, seeing a friend killed during combat, and finding out that former acquaintances and friends went to Vietnam and did not return home alive. See September 2014 VA examination. As a procedural matter, the Veteran also initially asserted that he was diagnosed with PTSD, which was related to his combat service. This service connection claim for PTSD was previously denied in the April 2019 Board decision and was not appealed to the United States Court of Appeals for Veterans Claims. Therefore, the symptoms and diagnoses of PTSD will not be discussed herein as it has already been adjudicated by the Board. To prevail on a service connection claim, the Veteran must show that he has a currently diagnosed disability during the appellate period. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Specifically, for psychiatric disorders, a current diagnosis under DSM-V is required to prevail on a service connection claim. Without a specific diagnosis for a psychiatric disability under the DSM-V criteria, the Veteran’s claim must fail. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). Private treatment records between June 2009 and February 2013 show multiple physical diagnoses but no psychiatric disability diagnoses. VA treatment records between June 2010 and June 2020 showed multiple negative depression and anxiety screenings. See e.g., June 2010, October 2010, February 2012, February 2013, March 2017, and June 2020 VA treatment records. The Veteran also denied feeling depressed and anxious numerous times in the VA treatment records and in VA examinations. See, e.g., September 2014 and November 2019 VA examinations, and February 2020 and June 2020 VA treatment records. Nevertheless, there were also positive PHQ-9 and GAD-7 screenings for feelings of depression and anxiety. Despite these positive screenings, the Veteran’s treating VA mental health clinicians did not render a mental health diagnosis other than alcohol use disorder during the appellate period. The Veteran was afforded a diagnostic interview for the trauma recovery program by a PTSD clinical team in December 2010. The evaluator was a licensed clinical social worker. The Veteran scored a 16 on the BDI-II, which indicated the Veteran had mild depression. The evaluator found that the Veteran did not meet the diagnostic criteria for PTSD. The diagnostic criteria for a depressive disorder was not discussed, and a depressive disorder diagnosis was not given. The Veteran was diagnosed with a DSM-IV Axis I diagnosis of alcohol abuse. The Veteran was afforded a VA psychiatric examination in September 2014. The examiner, a psychologist, only diagnosed the Veteran with alcohol use disorder. The Veteran did not have more than one mental disorder and did not have a TBI. Psychological testing using the MMPI-2-RF resulted in an invalid profile. The Veteran’s testing results showed non-credible reporting of psychiatric symptoms with over-reporting of somatic and physical problems. The Veteran’s responses showed an exaggerated presentation of his physical condition with an unusual combination of symptoms and attitudes. These responses suggested non-credible reporting of cognitive and somatic symptoms, whether conscious or unconscious. His results showed a very unusual combination of responses strongly indicative of non-credible reporting of memory complaints. The Veteran endorsed items that reflected a degree of psychopathology that is unusual even in a clinical population. The examiner noted that, “While it may be that these results represent a ‘cry for help,’ it is quite likely that there was some intentional exaggeration of the current symptom picture, possibly for secondary gain issues.” Interpretation of the clinical scales was not conducted. The Veteran was also given the World Health Organization (WHO) Disability Assessment Schedule 2.0 to assess the disability level across six domains, including cognition, self-care, getting along with others, mobility, life activities, and participation in society. However, the examiner concluded that considering the invalid MMPI-2 results and given that the Veteran took the WHO Disability Assessment at the same time, it was highly likely that the Veteran overreported on WHO evaluation as well. Additionally, the Veteran reported to the examiner that his biggest challenge at the time of the examination was paying his bills. The September 2014 VA examiner explained that to render a diagnosis of major depressive disorder (MDD), five symptoms under Criterion A were required. The Veteran endorsed only one symptom under criterion A, which was insomnia and hypersomnia. He denied experiencing a depressed mood most of the day nearly every day, markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day, significant unintentional weight loss or weight gain, psychomotor agitation or retardation nearly every day, fatigue or loss of energy nearly every day, feeling worthlessness or excessive inappropriate guilt nearly every day, diminished ability to think, concentrate, or to make decisions nearly every day, recurrent thoughts of death, suicidal ideations without specific plan, suicide attempts, or a specific plan for suicide. For generalized anxiety disorder (GAD), the Veteran also did not endorse experiencing all the symptoms required for a diagnosis. He endorsed feeling excessing anxiety and worry occurring more days than not for a t least 6 months about several events or activities, sleep disturbances, and the Veteran’s symptoms were not better explained by another mental disorder. It was questionable as to whether the Veteran’s symptoms were attributable to the psychological effects of a substance, such as alcohol. He denied restlessness, feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, anxiety, worry, and physical symptoms that caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran also denied symptoms associated with panic disorder and mania. Therefore, the Veteran was not diagnosed with a psychiatric disability, other than alcohol use disorder. The Veteran submitted an August 2015 private psychiatric evaluation by Dr. H.H.G., a private psychologist. Dr. H.H.G. diagnosed the Veteran with recurrent moderate major depressive disorder (MDD). The Veteran did not have any other psychiatric diagnoses and had not been diagnosed with a TBI. In conducting this evaluation, Dr. H.H.G. reviewed the claims file, reviewed the Veteran’s VA treatment records, and conducted a mental status examination. The Veteran admitted to self-medicating with alcohol in the past, but as of the time of the examination, he only drank on occasion when “things got bad.” He had been treated at VA by a psychiatrist every six months and had been prescribed Prazosin but was afraid to take it due to potential side effects. Dr. H.H.G. indicated the Veteran had symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of mood or motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including to a work and a work-like setting, and persistent delusions and hallucinations. The Veteran reported having “great ongoing difficulty with his symptom pattern,” and he no longer enjoyed the simplest of activities. On mental status examination, the Veteran’s attention was normal, and his concentration was variable. He reported increased trouble with short-term memory and struggled to remember even basic information. His speech flow was normal, although he was brief in his responses. Thought content was appropriate for the circumstances. His organization of thought was goal directed, and he reported overt hallucinations. His fund of knowledge, intellectual abilities, capacity for abstraction, ability to interpret proverbs, and judgement was average. The Veteran’s mood was anxious and nervous with restricted affect. He felt anxious and depressed. At this examination, the Veteran endorsed symptoms of depression, and he was vague in his responses, suspicious, and seemed rather paranoid when speaking with Dr. H.H.G. The Veteran seemed “cautious of this important interaction…” Dr. H.H.G. also noted he was socially isolated and withdrawn. He slept poorly but attended to his personal hygiene and performed most of his activities of daily living. The Veteran reported his symptoms had onset during Vietnam after a friend was shot in the head and killed when his M-60 malfunctioned. Many years after Vietnam, he received psychiatric treatment and was encouraged to go see his friend’s parents. He went to New York to meet them but was unable to face them. Dr. H.H.G. indicated this was a strong indicator of the severity of his problems. The Veteran reported hallucinations consisting of hearing his deceased mother’s voice, seeing shadowy figures, and feeling that scary people were in his house. He had one of these experiences when he was not drinking alcohol. He suffered from chronic sleep impairment, including insomnia, broken sleep, and nightmares, even with a CPAP machine. Dr. H.H.G reviewed medical journal articles, noting that people with diabetes were at increased risk for developing depression. In Dr. H.H.G.’s opinion, the Veteran’s depressive disorder began in service. Dr. H.H.G. noted a December 2010 VA treatment record that diagnosed the Veteran with “survivor’s guilt,” which was consistent with the events from his time in service and his current symptoms. Dr. H.H.G. believed that, although the Veteran had stressors significant enough to have caused PTSD and some of his symptoms were similar to PTSD symptoms, a depressive disorder was a more accurate diagnosis. Furthermore, Dr. H.H.G. also concluded that the service-connected diabetes mellitus and muscle group XM left thigh fragment wound scar were more likely than not contributing to the MDD. An April 2017 VA treatment record reported the Veteran had difficulty sleeping since the 1980s, and it had worsened in the last few years. The Veteran had frequent nightmares and hypnopompic hallucinations. The VA clinician noted the Veteran had symptoms of depression and anxiety, but only rendered a diagnosis for insomnia. A September 2018 DBQ for obstructive sleep apnea was completed by Dr. H.S., a physician. Dr. H.S. noted that the Veteran’s depressive disorder as likely as not aided in the development of and permanently aggravated the severe obstructive sleep apnea. In his rationale, Dr. H.S. noted that the Veteran had been diagnosed with MDD by Dr. H.H.G. in August 2015. The Veteran was afforded a November 2019 VA psychiatric examination. The examiner, a psychologist, noted the Veteran had been diagnosed with alcohol use disorder, which resulted in difficulties in his relationships and was the focus of the clinical mental health treatment at VA. The Veteran continued to drink daily, and it negatively affected his mood and sleep. The Veteran did not have a TBI and had not been diagnosed with any other mental health disorders. The Veteran slept between four and five hours per night. The Veteran described his mood as “mellow” and denied depression. His appetite was “not that much,” and his weight was stable. His energy was “ok.” He watched television, liked to cook, and gave away what he made to his friends. He denied difficulty with attention, concentration, memory, exaggerated startle response, and suspiciousness. He worried about his family and noted that he worried even when there was nothing to worry about. He denied racing thoughts, restlessness, and irritability. He was not short-tempered, but he did not like people who talked often. He avoided watching movies about Vietnam, and noted he sought mental health treatment because he became emotional watching movies about Vietnam. He thought about his friend that died in Vietnam every day. He enjoyed going to sports bars. There was no evidence of hypervigilance. The VA examiner indicated that while the Veteran reported “worry,” intrusive thoughts, and at times difficulty sleeping, these symptoms collectively did not result in a mental health diagnosis. The examiner concluded it was less likely than not that the Veteran had a depressive disorder. While the 2015 private examination diagnosed the Veteran with a depressive disorder, the Veteran denied depressed mood during this examination. A July 2020 VA addendum opinion again noted that, although the 2015 private evaluation diagnosed the Veteran with a depressive disorder, the Veteran denied depressed mood at the November 2019 examination. In January 2021, the Veteran submitted a statement that detailed being drafted and being sent to Vietnam. He also described withdrawing and isolating himself during service and experiencing discrimination when he returned from Vietnam. Over the years, the Veteran became a loner, did not want to be bothered, and avoided crowds and gatherings. He drank to stop his racing thoughts, and he was quiet. When he went to a bar, he sat in the corner booth alone. He did not desire to interact with anyone because he did not have enough patience for drama or additional stress that other people created. He had trouble with short term memory loss, was distracted easily, and forgot to complete tasks. He had difficulty concentrating and overthought situations. He did not handle stress well, was overwhelmed easily, and was unmotivated most of the time. He had difficulty sleeping but took CBD oil to calm him so he could fall asleep. He had difficulty maintaining relationships. He only trusted a handful of people and struggled to bond with others. He reported that a psychiatric treatment provider told him that he was wasting her time because he would not be open with her. He felt guilty about his partner who died, and he was unable to sleep because of it. He began therapy because he was seeing things. He developed a habit of keeping everything to himself and internalizing everything he went through in service and continued to bury his struggles. The Veteran indicated that he had tremors and the only thing that calmed them was drinking alcohol. His mental health was not getting better, and his physical conditions did not help with his depression or lack of motivation. After reviewing the evidence, the Board finds that a preponderance of the most probative evidence of record is against a finding that the Veteran has been diagnosed with a psychiatric disorder, other than the alcohol use disorder, under the DSM-IV or DMS-5 during the appellate period. Here, the VA medical opinions and examinations and VA treatment records are in direct conflict with the August 2015 private DBQ as to whether the Veteran has been diagnosed with a depressive disorder, to include MDD, during the appellate period. For the reasons discussed below, the Board finds the September 2014, November 2019, and July 2020 VA medical opinions and examinations, when read together and in light of the VA treatment records, are more probative than the August 2015 private medical opinion from Dr. H.H.G. The Board finds the VA treatment records to be of high probative weight. The Veteran’s treating VA mental health clinicians, after intermittent treatment for a decade, have only ever diagnosed the Veteran with alcohol use disorder, despite repeated mild depression and anxiety screenings using the PHQ-9 and the GAD-7 and numerous therapeutic sessions over many years. Additionally, the September 2014 VA examiner specifically listed the diagnostic criteria for both MDD and generalized anxiety disorder and noted which criteria the Veteran met and which criteria he did not meet for each diagnosis. The September 2014 examiner fully explained the conclusions given. Additionally, the November 2019 VA examiner also explained, while the Veteran may experience symptoms such as depression, worry, and sleep disturbances, collectively they did not rise to the level required to meet the diagnostic criteria for a depressive disorder. These opinions are consistent with each other and the other clinical medical evidence of record. Thus, when read together as a totality of the evidence, the Board assigns the VA examinations and the VA treatment records high probative weight. On the other hand. Dr. H.H.G., after a single examination, diagnosed the Veteran with MDD. Although Dr. H.H.G. based her diagnosis on a review of the claims file, VA treatment records, and a mental status examination, Dr. H.H.G. did not explain whether she evaluated the Veteran in-person, over the phone, or via videoconference, aside from a single reference that the Veteran was rather paranoid when “speaking” with her. Notably, the Veteran lives in Florida and the private psychologist’s office is in Indiana and she is licensed in Indiana and Kentucky. The record contains no information accounting for this geographical discrepancy or suggests that the psychologist ever treated the Veteran other than providing this opinion for compensation purposes. The Board acknowledges that psychologists can assess individuals through telecommunication methods; however, if alternative methods are used for examining a veteran, it should be identified and explained so that the results can be viewed and evaluated from an appropriate perspective. Dr. H.H.G.’s failure to explain the full scope and parameters of her assessment frustrates the Board’s ability to assess the comprehensiveness of her examination. Furthermore, Dr. H.H.G. did not discuss why the clinical symptoms reported to her were significantly more severe than the symptoms the Veteran reported in the VA clinical treatment records and two VA examinations throughout the pendency of the appeal. Dr. H.H.G.’s examination and conclusion that the Veteran met the diagnostic criteria for MDD appear to be based solely on the Veteran’s lay reports, which are wholly inconsistent with the other clinical evidence of record. For instance, Dr. H.H.G. wrote, “The Veteran details great ongoing difficulty with his symptom pattern. He remarks that he can no longer enjoy the simplest activities” and the Veteran “complains of increased trouble with short term memory.” Nevertheless, no independent evaluations were conducted to confirm whether these symptoms could be objectively confirmed, and there is no indication in the Veteran’s ongoing VA psychiatric treatment records of this level of symptomatology. On the contrary, the ongoing mental health treatment revealed milder symptoms throughout the pendency of the claim. Dr. H.H.G. also did not discuss the discrepancy between the Veteran’s symptom severity in her examination and the finding in the September 2014 VA examination that the Veteran was likely overreporting his symptoms, possibly for pecuniary gain. Additionally, Dr. H.H.G. did not diagnose the Veteran with alcohol use disorder, which is clearly diagnosed in the Veteran’s VA treatment records and VA examinations. Further, although she did not diagnose the Veteran with alcohol use disorder and found that he had no other psychiatric diagnoses other than the MDD, she paraphrased the September 2014 VA examination report as supporting evidence that the Veteran had MDD without explaining its significance, especially considering that it did not diagnose the Veteran with a depressive disorder. The Board also considered Dr. H.S.’ s obstructive sleep apnea DBQ, which noted the Veteran had been diagnosed with MDD by Dr. H.H.G. in August 2015. However, Dr. H.S. did not make an independent determination as to whether the Veteran met the diagnostic criteria for MDD and simply relied on Dr. H.H.G.’ s assessment, despite the weight of the remaining evidence of record to the contrary. For the reasons cited above, the Board finds the September 2014, November 2019, and July 2020 VA examinations and medical opinions to be more probative than Dr. H.H.S.’s August 2015 private evaluation. From a facial review of the examination reports, the VA examiners engaged in a far more thorough mental status examination than Dr. H.H.G. The VA examiners engaged in a thorough objective evaluation, whereas the private psychologist seems to have parroted the Veteran’s lay reports without any objective assessment and no analysis in light of the years of VA clinical treatment records. The Veteran indicated in his January 2021 statement that he had difficulty being open with other people. Yet, the Veteran also purportedly was open and forthcoming with Dr. H.H.G, despite Dr. H.H.G not living in the same geographic area and the Veteran only having contact with her once. The Board finds it unlikely that the Veteran would be more forthcoming with his symptoms and their severity with a clinician he did not know versus his treating clinicians at VA who he had sought treatment with intermittently for a decade. Additionally, the Veteran also noted that he eventually was able to be open with his treating VA psychiatric clinician, and yet, VA treatment records still never report a diagnosis of a depressive disorder during the appellate period. See, e.g., December 2010, April 2017 through April 2018, and February 2020 VA treatment records. The Veteran’s attorney asserted that the December 2010 VA treatment record diagnosed the Veteran with alcohol abuse and indicated his drinking problem began in service. Furthermore, the attorney contends that the December 2010 VA treatment records reported the Veteran was “suffering from depression…” See January 2021 brief. A careful review of this treatment record does show the Veteran was diagnosed with alcohol use disorder and notes symptoms of mild depression on the BDI-II scale. However, it does not diagnose the Veteran with a depressive disorder. Although the Veteran is competent to report feeling depressed, he is not competent to diagnose himself with a clinical depressive disorder. Furthermore, the Veteran’s attorney also asserted that the Veteran’s variously diagnosed mental disabilities through the years were related to service. As discussed above, a current diagnosis under DSM-V is required for compensation for psychiatric disabilities. Without a specific diagnosis for a psychiatric disability under the DSM-V criteria, the Veteran cannot meet the requirements of service connection for a psychiatric disability. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). The Veteran believes he suffers from a psychiatric disability, which is related to his service or a service-connected disability. Although the Veteran is competent to report symptoms, such as depressed mood, difficulty sleeping, and worrying, he is not competent to clinically diagnose himself with an acquired psychiatric disability. Psychiatric disorders, such as depressive disorders, are medically complex and requires specific education and training to diagnose. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). The Board also acknowledges the numerous medical journal articles relating the Veteran’s service-connected disabilities to psychiatric disabilities, such as diabetes and depression. However, these articles are irrelevant as to whether the Veteran has a current psychiatric disability, other than the alcohol use disorder which is discussed separately below. These particular medical journal articles do not address this Veteran or the evidence in this record. In the present case, the medical articles are of little probative value because no medical expert has opined regarding such a nexus in this particular Veteran based on such articles.” Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish “a plausible causality based on objective facts.” Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). The Board notes that while the April 2015 private examination indicated that the service-connected diabetes and thigh scar contributed to the Veteran’s depression, absent a currently diagnosed psychiatric disability, secondary service connection cannot be considered. As the preponderance of the evidence weighs against the claim, the benefit of the doubt doctrine is not for application, and the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement service connection for alcohol use disorder is denied. The Veteran asserts that the currently diagnosed alcohol use disorder had onset during or was otherwise related to service. To the extent that the Veteran has been diagnosed with alcohol use disorder during the appeal period, direct service connection for disability resulting from a claimant’s own alcohol abuse is precluded for all VA benefit claims filed after October 31, 1990. See VAOPGCPREC 7-99; VAOPGCPREC 2-98. Compensation cannot be awarded pursuant to 38 U.S.C. § 1110 and 38 U.S.C. § 105(a) either for primary alcohol use disabilities or for secondary disabilities that result from primary alcohol abuse. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Primary alcohol use disability means an alcohol use disability arising from voluntary and willful drinking to excess. Id. VA regulations state that no compensation shall be paid if a disability is the result of alcohol use. 38 C.F.R. § 3.301. For the purpose of this regulation, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301(d). See also 38 U.S.C. § 105; 38 C.F.R. § 3.1(m). As such, service connection is precluded as a matter of law for a disability etiologically related to alcohol use disorder. See 38 U.S.C. § 1110; 38 C.F.R. § 3.301 (d). For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that the preponderance of the evidence is against a finding that the Veteran has a current psychiatric disability, other than the alcohol use disorder, in accordance with the DSM-IV or DSM-5 criteria as required under 38 C.F.R. § 4.125(a). Additionally, to the extent that the Veteran has been diagnosed with alcohol use disorder, service connection is barred by statute and regulation. See Sabonis v. Brown, 6 Vet. App. 426 (1994). As the preponderance of the evidence is against the claim, or the benefit is barred as a matter of law, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Finally, the Board notes that neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). 4. Entitlement to service connection for OSA as secondary to a psychiatric disability is denied. The Veteran contends that his currently diagnosed obstructive sleep apnea (OSA) is caused or aggravated by a psychiatric disability. As an initial matter, the Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record. Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff’d sub nom Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). Nevertheless, this obligation “does not require the Board to assume the impossible task of inventing and rejecting every conceivable argument in order to produce a valid decision.” Id. “Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory.” Id.; see Shields v. Brown, 8 Vet. App. 346, 34950 (1995). In this case, the only theory of entitlement raised by the Veteran or the record is a secondary service connection claim. Therefore, the Board will limit its analysis to whether the OSA disability was caused by or was aggravated by a psychiatric disability. Turning to the evidence of record, the Veteran has a current OSA diagnosis during the appellate period. See October 2014 private sleep study. The Veteran was afforded a VA OSA examination in October 2014. The examiner, a physician, indicated the Veteran had not been diagnosed with OSA. The Veteran did report symptoms of daytime hypersomnolence which was a sign or symptoms of OSA. A sleep study had not yet been performed. The examiner noted that the Veteran had a poor sleep pattern for many years with daytime hypersomnolence. A sleep study was scheduled for the end of the month per his primary care physician. Subsequently, an October 2014 private sleep study was conducted, and the Veteran was diagnosed with severe OSA with symptoms of loud snoring and excessive daytime somnolence. He also had central sleep apneas. He was advised to avoid alcohol and sedatives, especially near times of sleep, due to increased risks associated with OSA. A February 2015 private sleep study again indicated the Veteran had persistent central sleep apnea with unsuccessful CPAP/BPAP titration. An April 2017 VA treatment record reported the Veteran had difficulty sleeping since the 1980s, and it had worsened in the last few years. The Veteran had frequent nightmares and hypnopompic hallucinations. An April 2018 VA treatment record noted the Veteran was using a new CPAP and it was significantly more comfortable and he had worn it nightly with success. An August 2018 VA sleep medicine treatment record indicated the Veteran was referred for evaluation for a sleep disorder. The Veteran was intolerant of the CPAP and wished to discuss alternative therapeutic options. The impression was that the Veteran had OSA, was using his CPAP without difficulty and was improving, and had some problem with sleep maintenance. Sleep hygiene maneuvers, such as not lying in bed awake and avoiding television and computer after 11 p.m.), were discussed with the Veteran. In September 2018, the Veteran was evaluated by Dr. H.S., a physician. After a review of the claims file, review of the Veteran’s medical records, and a September 2018 interview with the Veteran, Dr. H.S. diagnosed the Veteran with severe OSA, which was diagnosed after an October 2014 sleep study. A sleep study was ordered after he reported symptoms of insomnia, persistent daytime sleepiness, and was seen snoring and gasping for air when he slept. He did not diagnose the Veteran with central apnea or mixed components of both, but later in the DBQ noted the Veteran was noted to have severe complex OSA with a combination of both central apneas and OSA. The Veteran experienced persistent daytime hypersomnolence. Dr. H.S. opined that the Veteran’s depressive disorder as likely as not aided in the development of and permanently aggravated the severe OSA. On interview with the Veteran, he reported that the CPAP mask made him feel anxious and claustrophobic. He would occasionally remove the mask prematurely at night because of these feelings. His inability to use the CPAP as prescribed caused him to be excessively sleepy during the day and required that he take naps. The daytime hypersomnolence further aggravated his psychiatric symptoms, making them worse. The Veteran reported that he was still waking up in the middle of the nigh and removing the CPAP face mask because he felt like he could not breathe, and he felt anxious. Dr. H.S. noted a September 2014 VA examination report with a diagnosis of alcohol use disorder with symptoms of chronic sleep impairment. He also noted the August 2015 private examination by Dr. H.H.G., which diagnosed the Veteran with recurrent moderate MDD. Dr. H.S. noted that psychiatric disabilities were commonly associated with OSA. Dr. H.S. cited a recent study that compared depressed patients with non-depressed patients and found the depressed patients had a higher prevalence of OSA. The study found that, with CPAP treatment, the OSA and the psychiatric symptoms decreased, providing further evidence of comorbidity of these conditions. Dr. H.S. also submitted a copy of a medical journal article entitled, “Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort.” To prevail on a secondary service connection claim, the Veteran must be service connected for the primary disability. As discussed herein, the preponderance of the evidence is against a finding that the Veteran has been diagnosed with a psychiatric disability under the DSM-IV or DSM-5. Although the Veteran has been diagnosed with alcohol use disorder, and there is evidence that his excessive alcohol consumption aggravates his OSA, primary service connection is precluded for alcohol use disorder and any subsequent disabilities it causes or aggravates. Thus, the Veteran cannot prevail on a secondary service connection theory of entitlement for OSA since the preponderance of the evidence is against a finding that he has a currently diagnosed psychiatric disability that is subject to compensation. The Board considered whether the record raised the issue of direct service connection as a theory of entitlement. However, the evidence shows that the service treatment records are silent as to symptoms, diagnoses, or treatment of a sleep disability during service, he has not asserted that the OSA had onset during or is otherwise related to service, he has not provided an in-service event, injury, or disease that he believes caused the OSA, and he reported his difficulty sleeping had onset in the 1980s, more than 11 years after discharge from service. As the preponderance of the evidence is against the claim, or the benefit is barred as a matter of law, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Finally, the Board notes that neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). REASONS FOR REMAND 1. Entitlement to service connection for lung nodules is remanded. In the April 2019 decision, the Board remanded the service connection claim for lung nodules for another VA examination and etiology opinion because the May 2013 medical opinion indicated that the lung nodules were not lung cancer, and as a result, presumptive service connection was not warranted. The Veteran was afforded another VA examination in November 2019. The examiner, a physicians assistant, similarly concluded the lung nodules were not incurred in and were not the result of service because lung nodules were not consistent with a presumptive diagnosis associated with herbicide agents. The examiner noted that lung nodules occurred as the result of possible infection, inflammation, or malignancy. The November 2019 VA medical opinion is incomplete. In Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that when a Veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir., 1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). On remand, an addendum medical opinion should be obtained to determine if the lung nodules were, in fact, caused by herbicide agents, regardless of whether they are a presumptively service-connected disease to herbicide agents. Furthermore, additional explanation is required as to whether herbicide agents cause infection, inflammation, or malignancy that led to the Veteran’s development of lung nodules. 2. Entitlement to service connection for kidney stones is remanded. The Board remanded the service connection claim for kidney stones in the April 2019 Board decision to afford the Veteran a VA examination and obtain a medical opinion as to the nature and etiology of the kidney stones. As such, the Veteran was afforded a November 2019 VA kidney examination. The examiner, a physician’s assistant, indicated that the kidney stones were not incurred in or caused by service. Kidney stones were not a presumptive disease to herbicide agents. Furthermore, the examiner noted that risk factors for kidney stones were multifactorial and included but were not limited to a history of previous kidney stones, a family history of kidney stones, dehydration, high protein diet, sodium, and/or sugar, polycystic kidney disease, high levels of Systane, oxalate, uric acid, or calcium in the urine, and mediations. Furthermore, the examiner noted that the etiology of the prior kidney stones was indeterminate as no additional kidney stones have been collected for analysis and no further workup had been indicated. The November 2019 VA medical opinion is incomplete. As discussed above, when a Veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee, 34 F.3d at 1043-1044. On remand, a VA medical opinion as to direct service connection for the kidney stones should be considered. In addition, the examiner listed general potential risk factors for the development of kidney stones; however, she did not discuss how these risk factors applied to the Veteran. The examiner also noted the etiology of the kidney stones was undetermined but failed to explain how if the etiology of undetermined how a conclusion that it was not related to service could be reached. On remand, an addendum opinion with a thorough rationale should be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Obtain an addendum medical opinion from an appropriate clinician as to the nature and etiology of the lung nodules. After a thorough review of the claims file, the examiner should address the following: a) Provide an opinion as to whether it is at least as likely as not (a 50 percent probability or higher) that the lung nodules were caused by herbicide agent exposure service. A complete rationale should be provided for all opinions. The rationale cannot rely on the fact that lung nodules is not noted in the “Limited Evidence of No Association” category in the 2002 Agent Orange Update.” Rather, explain with complete rationale why the lung nodules are or are not related to exposure to herbicide agents. b) Provide a complete rationale discussing whether exposure to herbicide agents led to infection, inflammation, or malignancy in this Veteran which resulted in the currently diagnosed lung nodules. See November 2019 VA medical opinion. 3. Obtain an addendum opinion from an appropriate clinician as to the nature and etiology of the kidney stones. After a thorough review of the claims file, the examiner should address the following: a) Provide an opinion as to whether it is at least as likely as not (a 50 percent probability or higher) that the kidney stones were caused by herbicide agent exposure service. A complete rationale should be provided for all opinions. The rationale cannot rely on the fact that kidney stones is not noted in the “Limited Evidence of No Association” category in the 2002 Agent Orange Update.” Rather, explain with complete rationale why the kidney stones are or are not related to exposure to herbicide agents. b) If the examiner discusses risk factors for developing kidney stones, the examiner must identify which risk factors are applicable to this Veteran and explain how that factors into determining whether the kidney stones had onset during or were otherwise related to service. See November 2019 VA medical opinion. 4. Readjudicate the remanded claims. A. Yaffe Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.