Citation Nr: 21026915 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 14-14 782 DATE: May 4, 2021 ORDER Entitlement to service connection for a chronic headache disability is granted. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, the evidence of record favors a finding that the Veteran has a headache disability that is related to his service-connected fibromyalgia disability. 2. The Veteran does not have PTSD that is related to his military service. 3. The Veteran's acquired psychiatric disorder is not related to service, and is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a chronic headache disability have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.9 (2020). 2. Entitlement to service connection for acquired psychiatric disorder, to include as secondary to a service-connected disability, is not warranted. 38 U.S.C. §§ 1110, 1131 (2012) 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1989 to December 1989 and November 1990 to May 1991. The Veteran had subsequent Reserve service from 1991 to 1998, with various periods of active duty training and inactive duty training. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board at an August 2015 hearing in front of the undersigned. A transcript of the hearing is of record. In April 2018 and November 2020, the Board remanded these claims for further development. Service Connection Laws and Regulations 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 military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include psychosis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as psychosis is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The provisions of 38 U.S.C. § 1111 provide that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). A pre-existing injury or disease noted at entry will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The provisions of 38 C.F.R. § 3.306(b) provide that aggravation may not be conceded unless the pre-existing condition increased in severity during service. An important distinction between section 1111's aggravation prong of the presumption of soundness and section 1153 presumption of aggravation is the burden of proof. Under section 1111, the burden is on the Government to show by clear and unmistakable evidence that there was no increase in disability in service or, that any increase was due to the natural progress of the disease. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Under section 1153, however, the Appellant bears the burden of showing that his preexisting condition worsened in service. Once the veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2014). A pre-existing injury or disease will be considered to have been aggravated by active military, naval or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Chronic Headaches The Veteran's service treatment records are negative for complaints or treatments for headaches. The Veteran underwent a VA examination in May 2016. The VA examiner diagnosed the Veteran with tension headaches. The Veteran was afforded a VA examination for his claimed headache disorder in March 2020. The examiner concluded it was less likely than not that the claimed headache disorder was related to service as the examiner found that the objective examination was normal, and the Veteran's symptoms were subjective only. However, the examiner did not discuss the Veteran's lay reports of experiencing headaches as directed by the April 2018 Board remand instructions. Further, the examiner did not attempt to reconcile this opinion with either the prior May 2016 VA examination which diagnosed headaches or treatment records for headaches reflecting that migraine were present and the Veteran experienced muscular/tension/myofascial features in connection with his headaches. As a result, the examiner's opinion concluding the Veteran does not have a diagnosed headache disability because his symptoms are subjective, without discussing the clinical findings in the Veteran's treatment record or addressing the Veteran's lay reports, is inadequate. Per the November 2020 Board remand instructions, a VA records review was conducted in February 2021. The examiner opined that it was less likely than not that the Veteran's headaches were caused by the claimed in-service event, injury or illness. The examiner noted that the Veteran's post service records demonstrate headache complaints. The examiner also noted that the claims file demonstrated headache complaints most consistent with headaches that were a symptom of the Veteran's fibromyalgia. The examiner concluded that it was at least as likely as not that the Veteran's headaches were a symptom of his fibromyalgia. Notably, in a February 2020 rating decision, the RO granted service connection for fibromyalgia. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for headaches as secondary to his now service-connected fibromyalgia disability is warranted. As determined above, the evidence demonstrates that the Veteran has a current headache disability that was the result of his now service-connected fibromyalgia disability as the February 2021 VA examiner concluded that it was at least as likely as not that the Veteran's headaches were a symptom of his fibromyalgia. Therefore, the February 2021 positive nexus opinion of the VA physician provides the only competent medical opinion as to the relationship between the Veteran's current headache disability and his now service-connected fibromyalgia disability. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran's claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a headache disability as secondary to his service-connected fibromyalgia disability is granted. See 38 U.S.C. § 5107(b). Acquired Psychiatric Disorder to Include PTSD Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (1); see also, 38 U.S.C. § 1154(b). Similarly, if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (3). Otherwise, the law requires verification of a claimed stressor. Where a determination is made that the Veteran did not "engage in combat with the enemy," or the claimed stressor is unrelated to combat, the Veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must include service records or other credible evidence that supports and does not contradict the Veteran's testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. At 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V). 38 C.F.R. § 4.130 (2016). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the Court of Appeals for Veterans Claims (CAVC), or the United States Court of Appeals for the Federal Circuit. The Board notes that this claim was not certified to the Board until June 2015. Accordingly, this claim was pending before the agency of original jurisdiction on August 4, 2014, and DSM-5 applies to this claim. 79 Fed. Reg. 45094 (Aug. 4, 2014). Factual Background and Analysis The Veteran's service treatment records are negative for any complaints or treatments related to a psychiatric condition. The Veteran underwent a VA examination in October 2014. The examiner found that the Veteran met the criteria for an Axis I diagnosis of PTSD under DSM-5. The Veteran also had an Axis I diagnosis of bipolar disorder. The examiner noted that the Veteran's PTSD stressors were remembering when his parents fought as a child and physical and emotional abuse by his father when the Veteran was a preteen. The examiner indicated that the Veteran was exhibiting both PTSD and bipolar disorder and that neither of these were aggravated by the Veteran's military service. The Veteran reported having prior mental health interventions prior to his service but the Veteran did not have any mental health interventions in service and the Veteran did not claim to have any treatment in service. His PTSD was not diagnosed until recently which meant that the PTSD could not have been aggravated by his service. The examiner also found that the Veteran's bipolar disorder was not definitively diagnosed prior to service or during service and therefore there was no evidence to support that this would have been aggravated by service. The Veteran underwent a VA examination in May 2016. The examiner found that the Veteran did not have a mental disorder diagnosis. The examiner noted that he had previously diagnosed the Veteran with PTSD and bipolar disorder and the Veteran's PTSD stressor information was not related to service. On the current examination, the Veteran was very vague about his PTSD stressor information and did not meet the criteria for PTSD. The Veteran's testing was not consistent with any known mental diagnosis. In April 2018 the Board remanded the Veteran's claim for an acquired psychiatric condition, to include PTSD, to obtain a medical opinion because the Board found the record established the Veteran's standing as a combat Veteran. The Veteran underwent a VA examination in October 2018. The examiner diagnosed the Veteran with PTSD meeting DSM-5 criteria and Bipolar II. The examiner concluded the Veteran did not have a mental health diagnosis etiologically related to service. The Veteran was afforded a new psychiatric examination for his claimed psychiatric disorders, to include PTSD, in July 2020. This VA examination diagnosed the Veteran with Bipolar II disorder but concluded the Veteran did not have a diagnosis of PTSD meeting DSM-5 criteria. However, as noted by the Board in its November 2020 remand, neither the October 2018 nor the July 2020 medical opinions are adequate because they do not comply with the Board's April 2018 remand directives. Neither opinion considered all of the stressors as requested by the Board as neither discussed the Veteran's Desert Shield/Desert Storm combat stressors or fear when he lost control of his military vehicle on ice (with no accident) during a weekend active duty training drill. Further, the opinions did not discuss the Veteran's contentions regarding exposure to contaminants, potentially biological or chemical agents, during his combat deployment in Southwest Asia. Per the November 2020 Board remand instructions, a VA examiner performed a record review in February 2021. The examiner noted that the Veteran had been previously diagnosed with PTSD around the time of his 2014 VA examination as the examiner at the time noted that the Veteran's stressors were related to his childhood trauma. In 2018, the Veteran was again diagnosed with PTSD and the examiner explicitly noted that the diagnosis was related to his fear that his father would kill him and being baited by a drill sergeant into a fistfight. Examinations in 2016 and 2020 did not have PTSD diagnoses and the 2016 VA examiner specifically noted that the Veteran's self-reporting was unreliable. The examiner found that given the Veteran's consistent evaluations every 2 years since 2014 and consistent response of either no diagnosis of PTSD or a PTSD diagnosis related to childhood trauma and unrelated to service, it appeared less likely than not that the Veteran's PTSD was related to service to include his Desert Shield/Desert Storm combat stressors to include receiving incoming enemy fire, being within the bombing range and fear for the lives of other soldiers due to landmines and exposure to contaminants including biological or chemical agents, during his combat deployment in Southwest Asia and fear when he lost control of his military vehicle on ice (with no accident) during a weekend active duty training drill. The examiner also opined that it was less likely than not that the Veteran's acquired psychiatric disorder was incurred in or caused by the claimed in-service event, injury or illness. It was also less likely than not that the Veteran's acquired psychiatric disorder was proximately due to, the result of or aggravated by the Veteran's service-connected fibromyalgia or irritable bowel syndrome (IBS) disabilities. The examiner noted that the other diagnoses besides PTSD were bipolar disorder, anxiety, depression, mood disorder and insomnia. The examiner noted that the Veteran had very extensive documented examinations from 2014, 2016, 2018 and 2020. In each of the examinations, the examiners noted explicitly that the Veteran's stressors were all related to either a bipolar predisposition (bipolar) or childhood trauma (PTSD) or unreliable or inconsistent reporting. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for an acquired psychiatric disorder disability to include PTSD is not warranted. Initially, the Board notes that the record demonstrates that the Veteran reported mental health interventions prior to his service based on his family related stressors or watching his parents fight and his father verbally and physically abuse him. However, the Veteran is legally presumed to have been sound at service entrance as his enlistment examination is negative for complaints, treatments or diagnoses related to psychiatric treatment and there are no medical records documenting his psychiatric treatment prior to his service. Additionally, the October 2014 VA examiner specifically found that the Veteran's PTSD was not diagnosed until recently which meant that the PTSD could not have been aggravated by his service and that the Veteran's bipolar disorder was not definitively diagnosed prior to service or during service and therefore there was no evidence to support that this would have been aggravated by service. As such, the record does not clearly and unmistakably show that the Veteran had any psychiatric disability that preexisted his period of service. Therefore, the presumption of soundness is not rebutted and the claims become one for service connection on a direct basis rather than a claim based on in-service aggravation of a preexisting disability. See Wagner, supra. The Board parenthetically notes that even if the record clearly and unmistakably demonstrated that the Veteran had a psychiatric disability that preexisted his period of service, there is no indication in the Veteran's available service treatment records that any underlying psychiatric disability worsened during active service as a result of any acute in-service exacerbation. See Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002), and Hunt v. Derwinski, 1 Vet. App. 292 (1991). Notably, the most probative evidence indicates that an acquired psychiatric disorder disability was not worsened beyond the natural progress of the disability. Most notably, the October 2014 VA examiner specifically opined that while the Veteran was exhibiting both PTSD and bipolar disorder, neither of these were aggravated by the Veteran's military service. There is also no medical evidence of record from the Veteran's time in service or immediately thereafter suggesting that there was a permanent increase in the Veteran's acquired psychiatric disability beyond the natural progression of the disease during his active duty service. Regarding claims for service connection on a direct basis, the Board notes that there is some question as to whether the Veteran has a current diagnosis of PTSD. Notably, the VA examiners in 2014, 2018 and 2021 indicated that the Veteran had an Axis I diagnosis of PTSD both under the criteria of DSM-IV and DSM 5. Conversely, VA examinations in 2016 and 2020 found that the Veteran did not meet the criteria for PTSD. As noted above, the VA examiners provided a diagnosis of PTSD both under DSM-IV and DSM 5 while also providing substantial rationale for why the Veteran met the criteria as he described the Veteran's current psychiatric symptoms and how they related to the Veteran's stressors. As a result, when affording the Veteran the benefit of the doubt, the Board finds that there is at least an approximate balance of positive and negative evidence regarding the question of whether the Veteran has a current diagnosis of PTSD. However, while there are diagnoses of PTSD of record, the United States Court of Appeals for Veterans Claims (Court) has held that a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). As noted above, the record has established the Veteran's standing as a combat Veteran. However, while the Veteran is a combat veteran with a diagnosis of PTSD, the record demonstrates that the Veteran's PTSD was the result of nonservice related stressors. As noted above, the October 2014 VA examiner indicated that the Veteran's PTSD stressors were remembering when his parents fought as a child and physical and emotional abuse by his father when the Veteran was a preteen and that while the Veteran was exhibiting PTSD, this was not aggravated by the Veteran's military service. The examiner also noted that the Veteran's PTSD was not diagnosed until recently which meant that the PTSD could not have been aggravated by his service. In a February 2021 opinion, the VA examiner found that given the Veteran's consistent evaluations every 2 years since 2014 and consistent response of either no diagnosis of PTSD or a PTSD diagnosis related to childhood trauma and unrelated to service, it appeared less likely than not that the Veteran's PTSD was related to service to include his Desert Shield/Desert Storm combat stressors to include receiving incoming enemy fire, being within the bombing range and fearing for the lives of other soldiers due to landmines and exposure to contaminants including biological or chemical agents, during his combat deployment in Southwest Asia and fear when he lost control of his military vehicle on ice (with no accident) during a weekend active duty training drill. The Board affords the VA examiner's February 2021 opinions, which are supported by a detailed rationale and medical knowledge, great probative value. In forming his opinion, the VA examiner specifically discussed the Veteran's claimed in-service stressors for his PTSD. None of the competent medical evidence of record refutes these conclusions, and the Veteran has not presented or identified any such existing medical evidence or opinion. Thus, the Board finds the examiner's February 2021 opinions to be persuasive. As a result, there is no evidence of a link, established by medical evidence, between the current symptomatology and the Veteran's claimed in-service stressors. See 38 C.F.R. § 3.304(f). Based on above, the Board finds that the evidence of record does not show that the Veteran's claimed stressors for PTSD are causally related to his service. Thus, the evidence does not support that the Veteran's current PTSD disability is a result of his service. Regarding an acquired psychiatric disorder other than PTSD, after having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against a finding that an acquired psychiatric disorder had its onset in service. Initially, as the Board notes that there is a current diagnosis of bipolar disorder, anxiety and depression, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). As noted above, psychosis becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of psychosis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. However, bipolar disorder, anxiety and depression are not classified as a psychosis, and therefore may not be granted on a presumptive basis. Regarding service connection on a direct basis, the Veteran's service treatment records are again negative for treatment or complaints related to an acquired psychiatric disability and there are no clinical findings or diagnoses of any psychiatric disability during service or for several years thereafter. Significantly, the only medical opinions addressing the etiology of the claimed acquired psychiatric disability weigh against the claim as the February 2021 VA examiner opined that the Veteran's acquired psychiatric disorder was incurred in or caused by the claimed in-service event, injury or illness as the record noted explicitly that the Veteran's stressors were all related to either a bipolar predisposition (bipolar) or childhood trauma (PTSD) or unreliable or inconsistent reporting. None of the competent medical evidence of record refutes these conclusions, and the Veteran has not presented or identified any such existing medical evidence or opinion. Thus, the Board finds the examiner's February 2021 opinions to be persuasive. Regarding service connection on a secondary basis, the Board notes that the Veteran is service-connected for fibromyalgia and IBS. However, the Board finds that the weight of the evidence is against a finding that the Veteran's current acquired psychiatric disability is etiologically related to the Veteran's military service on a secondary basis. Notably, the only medical opinions addressing the etiology of the acquired psychiatric disability on a secondary basis weigh against the claim. The February 2021 VA examiner specifically opined that it was less likely than not that the Veteran's service-connected fibromyalgia or IBS caused or aggravated a diagnosed acquired psychiatric disability. None of the competent medical evidence currently of record refutes these conclusions, and the Veteran has not presented or identified any such existing medical evidence or opinion. Consequently, entitlement to service connection for an acquired psychiatric disability is not warranted on a direct or secondary basis. In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claims of entitlement to service connection. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). The Board notes the Veteran's contentions regarding the etiology of his claimed acquired psychiatric disability. To the extent that the Veteran himself contends that a medical relationship exists between his claimed current disabilities and service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). The Board finds that an acquired psychiatric disability is not a disability subject to lay diagnosis as this diagnosis requires medical training. More significantly, the Veteran does not have the medical expertise to provide an opinion regarding the claimed acquired psychiatric disability etiology. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the February 2021 VA examiners provided detailed rationales in support of their opinions and cited to the relevant evidence. For this reason, the VA examiners' opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). Thus, the Veteran's assertions that there is a relationship between his claimed acquired psychiatric disability and his service are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.