Citation Nr: 21031535 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 15-46 745 DATE: May 24, 2021 ORDER 1. Entitlement to service connection for a lumbar spine disability is denied. 2. Entitlement to service connection for a psychiatric disorder (including posttraumatic stress disorder (PSTD)), to include as secondary to a service-connected disability, is denied. FINDINGS OF FACT 1. A lumbar spine disability did not have its onset during active service, was not manifested by chronic arthritis to a compensable degree within one year of service discharge, and is not otherwise related to active service. 2. A psychiatric disorder, to include PTSD, did not have its onset during active service, is not otherwise related to active service (which lacks a verified in-service stressor), and is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for service connection for a psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 4.125 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1980 to February 1983, with subsequent Reserves service. The Veteran testified at a Central Office hearing in Washington, D.C. before the undersigned Veterans Law Judge in May 2017, and a transcript of the hearing has been associated with the claims file. These matters were previously denied by the Board in December 2018, after which the Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In May 2018, the Court granted a Joint Motion for Remand (JMR), vacating the Board's decision as it related to the issues on appeal, and remanding the matters for compliance with the instructions in the JMR. In November 2019, the Board remanded these matters for additional development, specifically to obtain the Veteran's complete service treatment records, to include documents pertaining to his service in the Army Reserves. In May 2020, the Army Records Processing Center provided the requested records and certified that other than the records provided, there were no further records associated with the Veteran that exist. Most recently, in August 2020, the Board reopened the Veteran's claim of entitlement to service connection for a lumbar spine disability and remanded the matter for adjudication on the merits by the Agency of Original Jurisdiction (AOJ). Additionally, the Board also remanded the Veteran's intertwined claim of entitlement to service connection for a psychiatric disorder, as it was claimed as secondary to his lumbar spine claim. The August 2020 Board also reopened and remanded a claim of entitlement to service connection for a hearing loss disability, which was subsequently granted in a March 2021 rating decision and is no longer before the Board on appeal. Since the August 2020 Board decision, the AOJ issued a March 2021 supplemental statement of the case (SSOC) which readjudicated the Veteran's claims on the merits. Given the substantial compliance with the August 2020 remand directives, the matters are properly returned to the Board for adjudication. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 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. For certain chronic diseases, including arthritis, service connection may be granted on a presumptive basis if the disease manifests within one year following service discharge. Even where service connection cannot be presumed, service connection may still be established on a direct basis. Service connection for PTSD specifically requires the presence of three particular elements: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. Regarding the second PTSD element as set forth in 38 C.F.R. § 3.304(f), the evidence necessary to establish the claimed stressor varies depending on the circumstances of the stressor and the nature of a veteran's service. A veteran's lay testimony alone may establish the occurrence of the claimed in-service event in four instances: (1) if the evidence establishes that the veteran was diagnosed with PTSD during service and the claimed stressor is related to that service; (2) if the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat; (3) if the claimed stressor is related to a fear of hostile military or terrorist activity and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and the veteran's symptoms are related to the claimed stressor; or (4) if the evidence establishes that the veteran was a prisoner-of-war under 38 C.F.R. § 3.1(y) and the claimed stressor is related to that experience. 38 C.F.R. § 3.304(f). Service connection may also be granted on a secondary basis for a current disability which is proximately due to or the result of a service-connected disease or injury. Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 1. Entitlement to service connection for a lumbar spine disability. The Veteran claims that the current lumbar spine disability is directly related to problems that began during active service following a lumbar puncture. At the May 2017 Central Office hearing before the Board, he testified that he first experienced back problems during active service when he was hospitalized for 30 days to determine the cause of blackouts that he was having and they "took liquid out of [his] spine." He stated that he was released to regular duty and returned to the hospital two weeks after complaining about his back, after which he was given a heat pad. He further stated that after the lumbar puncture, his back hurt while performing his military duties and following his discharge in 1983, his back problems continued on a continuous basis. Within an April 2021 brief, the Veteran's representative requested that the lumbar spine claim be granted given evidence of falls in service, continuity of symptomatology, and a current diagnosis. The representative appears to assert that a post-remand VA opinion is inadequate as it "appears to assume that everyone has health insurance and sick days." However, following a review of the evidence of record, and as discussed more fully below, the Board finds that the preponderance of the evidence is against the claim for service connection for a lumbar spine disability. The reasons follow. As to evidence of a current disability, a September 2012 x-ray documents an impression of mild degenerative changes of the lumbar spine, and an October 2012 MRI revealed lumbar disc bulge and degenerative changes resulting in lower back pain. Similarly, a November 2020 VA examination document a diagnosis of degenerative disc disease of the lumbar spine in October 2012. Thus, this first criterion is met. Regarding evidence of an in-service disease or injury, service treatment records do not document a chronic lumbar spine disability. The Veteran's February 1980 Report of Medical Examination at enlistment documents that a clinical evaluation of the Veteran's spine was normal, without any defect or diagnosis related to the lumbar spine. Additionally, the Veteran denied a history of recurrent back pain or other related symptoms within a concurrent Report of Medical History at enlistment. An undated treatment records documents the Veteran's complaint of a recent onset of diffuse back pain (based upon a notation of the Veteran's age, the Board reasonably approximates the date of this treatment record as December 1980). The Veteran reported that he had a lumbar puncture approximately two weeks before during work up for low back pain. He denied any trauma and stated that his back hurt during physical training; however, the resulting assessment noted that his pain did not fit with the reported anatomical location. Thereafter an August 1981 inpatient treatment record documents that the Veteran was admitted to the hospital for observation for post seizure episodes; however, no pathology was found following a spinal tap. Given the above, the Board concedes that service treatment records document complaints of back pain sufficient to satisfy the in-service element of the Veteran's claim. While an in-service disease or injury is shown in the service treatment records, the Board finds that there is no probative evidence that arthritis of the lumbar spine shown by x-ray evidence manifested within one year of the Veteran's service discharge so as to warrant a grant of presumptive service connection for arthritis as a chronic disease. The first showing of mild degenerative changes of the lumbar spine was in October 2012, which is many years following service discharge. Thus, service connection on a presumptive basis for lumbar spine arthritis as a chronic disease is not warranted. As to evidence of a nexus between the Veteran's current lumbar spine disability and active service, the Board finds that the preponderance of evidence weighs against this element of the Veteran's claim. Post-service VA treatment records from July 2008 document the Veteran's initial visit for VA treatment. He reported that he was hospitalized in service for a lumbar puncture, with no recurrence, and denied generalized aches and pains. Upon follow up in June 2009, he reported that he was doing fine, with no complaints. In November 2010, he denied any significant past medical history. In May 2011, he reported pain for three months on the left side of his neck, the top of his shoulder, and his collarbone; however, despite these specific reports of musculoskeletal pain, he did not report symptoms concerning his back or lumbar spine. In December 2011, the Veteran reported musculoskeletal complaints regarding pain in his left knee and left shoulder, but, again, he did not report symptoms concerning his back or lumbar spine. Private treatment records from January 2012 document that the Veteran was hit by a car while walking across the street, which resulted in an injury and pain to his left knee. Upon examination, he denied tenderness in his back. Subsequent VA treatment records from October 2012 document an MRI of the lumbar spine that showed degenerative changes and lumbar disc bulge. Upon follow up in January 2013, the provider noted that it was the first time the Veteran reported back pain and asked that the Veteran explain why this was the first time the examiner was being informed of back pain. The Veteran reported collapsing during active duty and being hospitalized for tests, including a spinal tap, and he thought that his back pain started then, with intermittent back pain thereafter that worsened in the 1990s. He also reported "[b]ack pain in low [left] side since [the] military," and stated that during active service "he was getting into the loaders and he says the area was small and he had to lift him[]self and 'jump' in there." When asked why he never reported back problems before, the Veteran stated that "[he] should have." The provider noted that a review of the Veteran's initial treatment notes did not mention back pain. VA treatment records from April 2013 document a lumbar x-ray that showed "[p]ossible minimal compression of L4" and "[m]ild degenerative change L4-L5," without any spondylolysis or spondylolistheses. Similarly, a September 2014 VA MRI revealed a loss of signal and decreased disc height in L3-L4 and L5-S1 discs, which was suggestive of degenerative disc disease. Upon VA back examination in October 2013, a VA examiner diagnosed mild low back strain with mild degenerative change at L4-L5 since 2013. The Veteran reported that he developed back pain after collapsing while on duty. The examiner noted that a review of the claims file revealed an undated note that documents that the Veteran, who was 20 years old at the time, was seen for a complaint of diffuse back pain; however, the provider at the time did not diagnose a back condition but stated that the reported "pain does not fit anatomical location." The examiner noted the Veteran was treated with asprin and instructed to alternate his stance from side to side. Aside from this one entry, the VA examiner was unable to find additional documentation regarding a back condition. The examiner acknowledged the Veteran's current subjective complaint of back pain, which is constant in nature. Ultimately, the VA examiner opined that the Veteran's current back condition is not related to his back condition while in the military. The examiner stated that the in-service complaint of back pain did not result in a diagnosis of a back condition, and the provider noted that the reported "pain does not fit anatomical location." Additionally, the examiner noted that although the Veteran's initial medical visit to the Philadelphia VA Medical Center was in 2008, the Veteran did not mention a problem with his back until 2012. As such, based on a review of the claims file, the examiner concluded that the Veteran's current back condition is not related to his military service from 1980 to 1983. As noted above, following the August 2020 Board decision that reopened the Veteran's lumbar spine claim, the matter was remanded for adjudication on the merits. Thereafter, the Veteran was afforded an additional VA spine examination in November 2020. At that time, the Veteran reported that his condition had its onset during active service in the 1980s, when he was having episodes of blacking out and falling down, and he underwent a lumbar puncture for further evaluation. He reported ongoing lower back pain since that time. Following the examination, the VA examiner diagnosed degenerative disc disease of the lumbar spine since October 2012 and opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner noted that the Veteran had been diagnosed with degenerative disc disease of the lumbar spine, which is a chronic degenerative condition that is common and increases in frequency with aging and is most often related to the natural aging process. The examiner stated that the Veteran lacked continuity of care from the time of his in-service back complaints; therefore, it is less likely than not that the Veteran's degenerative disc disease of the lumbar spine is caused by his complaints of back pain during service. The Board finds that the negative nexus opinions of the October 2013 and November 2020 VA examiners are probative evidence that weigh against the Veteran's claim. The examiners considered the Veteran's medical history, including his in-service complaints of back pain and the clinical findings documented within the records, as well as his lay reports of ongoing back problems since that time. Each examiner noted that the objective evidence of record failed to document ongoing complaints of back pain in the years following active service. The lack of complaints of back pain in the years following active service is supported by the credible evidence, which the Board will address in more detail below. Thus, the examiners provided rationales for their opinions, which were based upon the accurate facts of the case and medical principles. As such, the Board finds that the Veteran's lay reports of ongoing symptoms following the in-service back pain to be not credible, which is explained below. Following a July 2012 Social Security Administration (SSA) disability claim for various disabilities, including back pain, private treatment records from February 2013 document that the Veteran sustained post-traumatic injuries, including lumbar disc protrusion/bulging and lumbar myositis, when he was struck by a car on January 10, 2012. Notably, at that time, the Veteran denied any prior history of "low back trauma." He stated that when he was in the military many years ago, he suffered a syncopal episode and underwent a lumbar puncture, "but there were no complications from that procedure." The private physician, Dr. Geoffrey Temple, noted that the spinal lumbar puncture itself was not due to a primary low back injury, rather, it was from the syncopal episode, the cause of which was never found. The private physician acknowledged that the Veteran had undergone a lumbar MRI in October 2012, which found "a broad disc bulge at L5-S1 and a central disc protrusion at L3-4 along with a disc bulge at L4-5" and "degenerative changes," and opined that "the disc bulges and the disc protrusion are related to the trauma that occurred on January 10, 2012" while "the degenerative changes preceded by were aggravated by the trauma of January 10, 2012." Similarly, a favorable August 2013 SSA decision states that the Veteran asserted disability "because he was injured as a pedestrian on January 10, 2012, when he was hit by a car, and that since that time, he has had a severely incapacitating combination of musculoskeletal, auditory, and mental disorders." The Board finds that this evidence also weighs against the Veteran's claim, as it identifies the January 2012 car/pedestrian accident as the resulting cause of the Veteran's back injury and current disability. Significantly, the February 2013 private physician opined that the disc bulges and protrusion were directly related to that trauma, and to the extent that he stated that the degenerative changes in the Veteran's back preceded the January 2012 accident, the Board finds that this is consistent with the November 2020 VA examiner's opinion, which noted that degenerative disc disease of the lumbar spine is a chronic degenerative condition that is common and increases in frequency with aging and is most often related to the natural aging process. In other words, although the private physician stated that the Veteran's lumbar spine degenerative changes existed prior to his January 2012 accident, the probative November 2020 VA examiner's opinion correlates these degenerative changes to the natural aging process, rather than the Veteran's assertion that such changes were related to his isolated complaints of back pain during active service over 30 years before. While the Veteran is competent to report observable symptoms that he experienced in service and since service, he is not competent to directly link the current lumbar spine disability to active service, which requires medical expertise. In this regard, the question of causation in this case involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion regarding a nexus is nonprobative evidence. Moreover, to the extent that the Veteran has asserted during his VA disability claim that his back pain first had its onset during active service and has continued since that time, the Board finds that such allegation is not credible, as he has made inconsistent statements in this regard. For example, when seen in February 2013 in relation to injuries he sustained from the January 2012 accident, when he was hit by a car, he reported having the lumbar puncture in service and that "there were no complications from that procedure." He also denied prior trauma to his low back at that time. The facts she reported at the time of the February 2013 private medical record would indicate that he was not having ongoing low back pain leading up to the January 2012 accident. His conflicting statements damage the probative value of his current assertions regarding ongoing back symptoms since active service. Consistent with this finding that the Veteran has provided inconsistent statements is a separate statement documented in the February 2013 examination report from Dr. Temple. Dr. Temple wrote that the Veteran had a past medical history of depression and added that he was not "suffering from depression prior to January 10, 2012. He is now under the care of a psychiatrist at VA because of ongoing pain and impairment." However, VA treatment records show that in May 2011, the Veteran reported that had been feeling "not right" and "depressed" for the past couple of years and he was diagnosed with depressive disorder, not otherwise specified. In June 2011, he was referred to the behavioral health lab due to depression. Thus, what was documented in the February 2013 medical record from Dr. Temple is directly contradicted by VA treatment records. This shows that the Veteran's inconsistent facts are not limited to the back/lumbar spine (he also provided inconsistent facts regarding his left knee, which is addressed in the August 2020 Board decision, see pp. 8-9). These inconsistent facts have damaged the Veteran's overall credibility. Thus, the Board finds that the Veteran's allegations, overall, lack credibility. In conclusion, for all the reasons discussed above, the Board finds that the preponderance of the evidence weighs against the Veteran's claim for service connection for a lumbar spine disability. As such, there is no reasonable doubt to be resolved, and the claim for service connection is denied. 2. Entitlement to service connection for a psychiatric disorder (including PSTD), to include as secondary to a service-connected disability. The Veteran asserts that he has a psychiatric disorder, to include PTSD, which is a result of his active service, and/or is secondary to a service-connected disability. At the May 2017 Central Office hearing, the Veteran testified that he experienced depression as a result of his physical disabilities, including his left knee, back, and hearing loss. He clarified that he was not claiming that he developed a psychiatric disorder during active service from February1980 to February 1983, but that his claimed disorder was secondary to his physical disabilities The Veteran further reported that his treating doctor opined that the depression and mental health issues are all related to his physical condition. Within an April 2021 brief, the Veteran's representative asserted that the Veteran's PTSD was related to an in-service stressor from Army training exercises, which involved "as much realism as possible," and that based upon a favorable post-remand VA medical opinion, a grant of service connection for PTSD was warranted. However, following a review of the claims file, and for the reasons discussed further herein, the Board finds that the preponderance of the evidence weighs against the Veteran's claim of entitlement to service connection for a psychiatric disorder. The reasons for this decision follow. As to evidence of a current disability, VA treatment records from May 2011 document an assessment of depressive disorder. In June 2011, an assessing practitioner stated that the Veteran's reported symptoms are consistent with past and current major depression, generalized anxiety, and PTSD. Upon initial psychiatric evaluation in February 2012, the Veteran was diagnosed with major depression, and he received ongoing treatment thereafter. Additionally, an October 2020 VA mental disorders examination documents a diagnosis of PTSD. As such, the requirement of a current disability during the pendency of his claim has been met. As to evidence of an in-service disease or injury, service treatment records do not document complaints, treatment, or diagnosis of a psychiatric disorder or related symptoms. The Veteran's February 1980 Report of Medical Examination at enlistment documents that a normal clinical psychiatric evaluation, without any psychiatric defect or diagnosis. Additionally, the Veteran denied a history of depression, excessive worry, or other related psychiatric symptoms within a concurrent Report of Medical History at enlistment. Subsequent service treatment records do not document psychiatric complaints, treatment, or diagnosis. At the May 2017 hearing when the Veteran described having psychiatric symptoms due to his knee, his back, and not being able to hear well, the undersigned clarified with the Veteran that he was not alleging that he developed psychiatric symptoms during service, and the Veteran confirmed that fact. This was a statement against interest, which the Board finds makes this admission highly probative. Given the above, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran developed psychiatric symptoms during service. Additionally, the probative evidence of record weighs against a finding of a nexus between a current psychiatric disorder and the Veteran's active service. Post-service VA treatment records from November 2010 document the Veteran's denials of any significant past medical history. In May 2011, a screening test for depression was negative, although that same month, the Veteran reported that he has been feeling "not right" and depressed for the past couple of years. He noted a decreased interest in things along with sleep problems, and reported problems in the relationship with his girlfriend and frequent arguments. Notably, the Veteran denied experiencing any depressive episodes in the past. His condition was assessed at that time as depressive disorder, not otherwise specified (NOS). A subsequent June 2011 suicidal risk assessment documents the Veteran's denial of active suicidal ideation, although he endorsed daily thoughts of death lasting for one or a few hours, which tended to occur when he is alone. He reported one prior suicide attempt in the 1980s when he placed a gun to his head but was interrupted by a family member he stated that he was involved with substance use and "crazy things" at that time. He reported current protective factors including reasons for living, such as his grandchildren, girlfriend, responsibility, engagement in work and school. The resulting estimated risk level was low. Following a June 2011 structured telephonic assessment, the examiner documented that the Veteran's reported symptoms were consistent with past and current major depression, generalized anxiety, and PTSD. In December 2011, after he had missed several follow-up appointments, the Veteran was again referred for mental health consultation. A February 2012 psychiatric initial evaluation documents that the Veteran reported that his time in the Army was "the best" and he regretted not staying in longer because of how difficult it has been for him to sustain employment and relationships since then. He again reported one prior suicide attempt years before when using heroin. The resulting Axis I diagnosis was major depression, and a concurrent screening test for PTSD was negative. These facts show that the Veteran was not reporting psychiatric symptoms as being related to his period of active duty, including the suicide attempt that occurred in the 1980s, which he reported was while he was using heroin. Again, while seeking treatment for the psychiatric symptoms, the Veteran was not attributing the symptoms to service to include an incident that occurred during service. Statements made while seeking treatment tend to be highly reliable, and the Board finds that such statements documented in the treatment records to be probative. Thereafter, the Veteran received ongoing mental health treatment through VA, and his follow-up visits, such as one from January 2016, consistently document that the Veteran attended mental health treatment and medication management visits reliably on a three-month basis. His primary complaint was depression associated with his pain and disability due to arthritic deterioration of his knees and back. His other primary affliction involved conflict with a "very temperamental" girlfriend; however, this situation improved when he was able to move to a nice, quiet neighborhood. The Veteran's July 2012 SSA disability claim listed disabilities, including depression. As discussed above, the February 2013 private treatment record from Dr. Temple documented that the Veteran was not suffering from depression prior to January 2012, but that he was under the care of a psychiatrist at the VA because of ongoing pain and impairment from the January 2012 motor vehicle accident. Similarly, the favorable August 2013 SSA decision documents that the Veteran asserted disability due to a January 2012 injury when he was hit by a car, and that since that time, he has had a severely incapacitating combination of musculoskeletal, auditory, and mental disorders. As noted above, following the August 2020 Board decision that remanded this matter, the Veteran was afforded an additional VA examination in October 2020. At that time, a VA examiner diagnosed PTSD, with other medical diagnoses relevant to the understanding or management of the Mental Health Disorder noted as chronic pain that exacerbates symptoms of PTSD. The examiner noted that there was no relevant history based on the current exam and review of any available medical records to confirm pre-military or military mental health history. Regarding post-military mental health history, the examiner noted that the Veteran was initially treated for PTSD in 2011 following a positive PTSD screen, and that he was diagnosed at the Philadelphia VA hospital in June 2011 and continued to have positive PTSD screens over the course of the years since that time. Regarding the claimed PTSD stressor, the Veteran reported that while serving as a hawk missile crewman, he was proximal and indirectly involved in wargame activity, stating that rocket and missile attacks were simulated with live ammunition and he was frequently proximal to exploding ordinance, causing him to be fearful for his life and the safety of those with him. The examiner noted that this stressor met the criteria to support a diagnosis of PTSD; however, the stressor was not related to the Veteran's fear of hostile military or terrorist activity, as the Veteran was involved in a U.S. military exercise on American soil, and the stressor was not related to in-service personal assault or military sexual trauma. The VA examiner opined that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner stated that the Veteran has medical records since 2011 with a diagnosis of PTSD, with subsequent treatment, and the Veteran has no other stressful events that he has reported other than his service as a hawk missile crewman, which he reported continued nightmare and flashback conditions secondary to that duty. The examiner also noted that the Veteran's induction physical was absent for any similar psychiatric concerns. Given this, the examiner concluded that the Veteran's medical records support that any currently diagnosed condition(s) related to the Veteran's claimed PTSD was at least as likely as not related to the claimed in-service stressor. The examiner further opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition, as the VA examiner was unable to identify any medical records that supported that the Veteran's PTSD is a product of either his hearing loss or his orthopedic low back concerns. The Board has considered the October 2020 positive nexus opinion rendered by the VA examiner; however, for the reasons discussed below, the Board finds that the positive direct nexus opinion is of no probative value, as it is based upon an inaccurate factual premise. During the examination, the Veteran reported a stressor event while serving as a hawk missile crewman, where he was proximal and indirectly involved in wargame activity, with rocket and missile attacks that were simulated with live ammunition, and he was frequently proximal to exploding ordinance which caused him to be fearful for his life and the safety of those with him. As noted above, a March 2021 submission by the Veteran's representative similarly asserts that the Veteran's PTSD is related to in-service Army training exercises, which involved "as much realism as possible." However, prior to the Veteran's report of this stressor event upon examination in October 2020, he had consistently claimed entitlement to service connection for a current psychiatric disorder on a secondary basis, rather than as directly due to active service. At the May 2017 hearing, he had specifically stated he did not have psychiatric symptoms, which statement the Board finds is reliable for the reasons discussed above (a statement against interest). As such, his subsequent statements of an in-service stressor made in the context of his claim for VA disability compensation benefits are of no probative value. As stated above, the Board finds that the Veteran has provided inconsistent facts on more than one occasion and on more than one subject matter, which has damaged his overall credibility. Thus, the allegation he has made of an in-service event is found not credible. Regardless, the Veteran's lay testimony alone may not establish the occurrence of his claimed in-service stressor event. First, the probative evidence does not document an in-service diagnosis of PTSD. Second, the probative evidence does not establish that the Veteran engaged in combat during active service. Third, his reported stressor is not related to a fear of hostile military or terrorist activity. And, finally, the probative evidence does not establish that the Veteran was a prisoner-of-war. As such, his uncorroborated lay reports of his in-service PTSD stressor are insufficient to establish the occurrent of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Therefore, to the extent that the October 2020 VA examiner's positive nexus opinion relies on the Veteran's reported PTSD stressor, it is also of no probative value in the context of the Veteran's claim. Additionally, the Board notes that a January 2021 deferred rating decision documents that the October 2020 VA examiner linked the Veteran's current diagnosis of PTSD to a specific training incident while on active duty. Thereafter, VA sent the Veteran a January 2021 notification letter, which requested that he complete and submit a PTSD stressor form to allow VA to attempt to verify his stressor. The Veteran was specifically notified that VA needed specific details of the stressful incident in service that resulted in his PTSD. He was also notified that he should respond to the request within 30 days, and that if he did not respond, VA would proceed to make a decision on his claim, including a potential denial of his claim. Following the January 2021 letter, the Veteran did not directly respond or submit any additional supporting evidence regarding his claimed in-service PTSD stressor. In March 2021, the Veteran's representative responded that he had no additional evidence to submit in support of the Veteran's claim. While the Veteran's lay statements of record are competent insofar as they report observable symptomatology, to the extent that the Veteran's lay statements further attempt to diagnose a certain psychiatric disorder or provide a nexus relating a psychiatric disorder to his active service, the Board finds that such statements are of no probative value, as the Veteran lacks the requisite medical and psychiatric expertise. In this regard, the question of diagnosis and causation involve a medical subject concerning an internal physical and psychiatric process extending beyond an immediately observable cause-and-effect relationship. As such, the question of diagnosis and/or etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Additionally, as noted above, to the extent that the Veteran asserts that a current psychiatric disorder is related to an in-service stressor event, the Board finds that the uncorroborated lay statements of record concerning an in-service PTSD stressor event lack probative value. Notably, such reports are also inconsistent with post-service treatment records in which the Veteran himself related his psychiatric symptoms to health and relationship concerns. Further, as a result of the Veteran's damaged credibility, any facts alleging in-service psychiatric symptoms or a stressor are not credible. Without evidence of an in-service disease or injury, service connection for a psychiatric disorder is not warranted. Finally, to the extent that the Veteran has claimed that a current psychiatric disorder is secondary to a service-connected disability, the Board is mindful that the Veteran's only service-connected disabilities are hearing loss and tinnitus. Significantly, there is no probative competent evidence of record relating a current psychiatric disorder to such disabilities, and the Veteran's own lay assertions in this regard lack probative value, as the Veteran does not have the competence in psychiatry or audiology to render a secondary nexus opinion relating a complex psychiatric disorder to an internal condition such as hearing loss or tinnitus. For all the reasons laid out above, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a psychiatric disorder. As the preponderance of the evidence is against the Veteran's claim, there is no reasonable doubt to be resolved, and the claim for service connection is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chad Johnson, 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.