Citation Nr: 21039777 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 11-27 413 DATE: July 1, 2021 ORDER Entitlement to service connection for a liver disability is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), to include as due to a service-connected disability, is remanded. Entitlement to service connection for a seizure disorder, to include as due to a service-connected disability, is remanded. FINDING OF FACT The evidence is against finding that the Veteran has had liver-related disability at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for a liver disability have not been satisfied. 38 U.S.C. §§ 1110,1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1974 to January 1977 and from December 1977 to November 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued by a Department of Veterans Affairs (VA) regional Office (RO). It was previously before the Board in December 2016, September 2019, and January 2021, where the issues were remanded for additional development. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in August 2016. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. Service Connection for a Liver Disability The Veteran asserts that he has a liver disability that is related to service. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In a September 2010 statement, the Veteran reported that he contracted hepatitis of an unknown origin while serving overseas, possibly due to contaminated drinking water. He also reported having blood drawn on various occasions. During his August 2016 Board hearing, the Veteran reported that he did not know if he had any form of hepatitis or residuals thereof. He asserted that he had been diagnosed with infectious hepatitis or a liver condition during service, but did not know which type, and denied any exposure to bodily fluids during service. For the following reasons, however, the Board finds that the Veteran does not have a current diagnosis of any disability involving the liver for service connection purposes and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). By way of history, the Veteran's service treatment records (STRs) are silent for any complaint, treatment, or diagnosis of a liver disability, to include infectious hepatitis. While records indicates he underwent testing during service in approximately December 1976 to rule out mononucleosis hepatitis and/or hepatitis A, results of such are not associated with the record. During a March 1997 DBQ to evaluate the Veteran's low back disability, the examiner noted that the Veteran had a history of hepatitis B; laboratory results at the time, however, appeared to be non-reactive. VA treatment records dated in April 2011, an annual comprehensive assessment, indicates that an Axis III diagnosis included "medical condition" and listed infectious hepatitis to include liver condition, without further comment or physical findings. Based on the foregoing, as it was unable to determine if such blood tests reveal residuals of any hepatitis or any liver disability, the Board remanded the Veteran's claim in December 2016 for the RO to afford the Veteran a VA examination in order to determine the etiology of any diagnosed liver disability, to include infectious hepatitis. During an April 2017 VA examination, the Veteran reported that during service he began urinating dark orange and sought treatment. He reported that he was told that his urine was orange because he drank something orange, and that by the fourth attempt at treatment, he was checked and treated in isolation for hepatitis for some period of time which eventually cleared. He reported that he was advised to avoid certain foods, and that he did not seek treatment for such after separation from service and has not been told anything about his liver since separation from service. The examiner noted a provisional diagnosis of mononucleosis-associated hepatitis in the Veteran's STRs and stated that his report of dark urine with enlarged nodes is a known complication of mononucleosis, and that all records indicated that it resolved without any residuals. After review of the Veteran's STRs and post-service records, the examiner concluded that there was no clinical or laboratory evidence of a chronic liver condition, noting specifically that testing in 2003 was negative for hepatitis A, B, or C, which ruled out any infection at the time as well as any prior infections. In its September 2019 remand, however, the Board noted that the results of the aforementioned laboratory testing in 2003 was dated many years prior an April 2011 annual comprehensive examination at his local VA Medical Center (VAMC) that indicated a history of "infectious hepatitis to include liver condition." As such, the Board remanded the claim again in September 2019 for the RO to afford the Veteran a new VA examination to determine the etiology of any diagnosed liver disability, to include infectious hepatitis. Significantly, the Board directed the examiner to conduct appropriate laboratory testing to determine of the Veteran has liver disability, to include infectious hepatitis, or any hepatitis. In a December 2019 examination, the examiner again noted that the Veteran was diagnosed in service with mononucleosis with hepatitis. However, the examiner, noted that the medical record was silent in regard to any current liver condition or any chronic progressive complaints of any liver condition. His hepatitis A, B, and C antibodies the examiner explained, have never been positive and he has never had any exposure to any hepatitis viruses. Rather, he experienced and inflamed liver in service due to a "normal young adulthood virus" in service, mononucleosis, which resolved. As the Board noted in its January 2021 remand, however, the examiner did not conduct the appropriate laboratory testing ordered by the Board. The examiner also did not consider the Veteran's in-service testing to rule out hepatitis A, his lay statements describing exposure to drinking water overseas, or his assertion of repeated in-service blood tests. Thus, he claim was once again remanded for an additional examination, which was provided in February 2021. After review of the evidence of record, which included laboratory testing, the examiner opined that the Veteran does not have a current liver disability diagnosis, explaining that his hepatitis in service (inflammation of the liver) was a result of his contracted mononucleosis virus, which was treat at the time and resolved. The examiner further stated that, although he reported drinking water overseas, his records are silent for current liver condition, any chronic progressive complaints of a liver condition since that time, or any actual exposure to the hepatitis virus. Mononucleosis is an infectious condition that resolved completely. Based on the foregoing, the Veteran's claim must be denied. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1131. In the absence of proof of a current diagnosis of the claimed disability, service connection for that disability cannot be established. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board acknowledges the holdings in Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) and Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 398 (2020) which held the definition of "disability" in 38 U.S.C. § 1110 (and by implication 38 U.S.C. § 1131) includes any condition that results in functional impairment of earning capacity. Here, however, not only is there no diagnosed condition, the record does not reflect any symptoms suggestive a liver disability that result in any level of functional impairment. While the Veteran may believe he has a current liver disability, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND While the Board sincerely regrets even further delay, the Veteran's remaining claims must again be remanded for additional development. The Board stresses that this issue has been on appeal for more than a decade and is being remanded by the Board for the fourth time. All efforts should be made to ensure substantial compliance with the Board's below directives. 1. Service connection for an acquired psychiatric disorder. The Veteran asserts that his acquired psychiatric disorder, to include PTSD, to include as secondary to personal assault, was incurred during service. Upon VA examination in December 2019, he was diagnosed with an "other specified personality disorder," "mild neurocognitive disorder due to multiple etiologies," and an "other specified and stressor related disorder." By way of background, the Veteran reported in a September 2010 statement that he was seen during service for hearing voices and seeing things and asserted that such was not an attempt to get out of service, that he wanted to stay in service and worked on his reading and writing skills in order to pass the test to stay. Indeed, STRs dated in May 1974 indicate that the Veteran complained of nerves and was diagnosed with nervous tension. In February 1976, the Veteran complained of fear from auditory and visual hallucinations and reported experiencing such just before entry into service. He asserted that as he became more frightened, his hallucinations were harder to control. While the treatment provider noted the Veteran's in-service discipline problems and decreased performance, no actual psychiatric diagnosis was recorded, and it was noted that the Veteran had child-like manipulation in an underlying anti-social personality. An additional in-service psychiatric evaluation in February 1976 indicates that the Veteran was diagnosed with situational adjustment reaction, in resolution, and the examiner noted that visions and voices were normal cultural expressions of fear and nervousness. His military personnel records note that the Veteran was discharged from service for unsuitability. Post-service, the Veteran complained of nervousness during VA treatment as early as February 1988. In May 2006, during VA treatment, the Veteran was diagnosed with mood disorder, second to his general medical condition (specifically, sleep apnea) and personality disorder. VA treatment records dated in December 2008 indicate that the Veteran was diagnosed with dementia and mood disorder attributed to his general medical condition. In December 2010 and December 2011, he was diagnosed with depressed mood and a mood disorder, respectively. During additional VA treatment in December 2011, it appears that the Veteran was also diagnosed with PTSD. Upon VA examination in August 2011, the Veteran reported his pre-service and in-service history to include reported chaos, including both physical problems and psychosocial distress. He reported that he impregnated both his girlfriend and wife at the same time, his marriage failed, and his father was ill. The Veteran also reported that during service he was "left for dead" and beat up and pistol-whipped and tied up to the ship, and that he was harassed and the target of disciplinary actions. The examiner noted the Veteran's in-service report of experiencing hallucinations prior to service, as well as the fact that he was attempting to get discharged, and found that his behavior was inappropriate before, during, and after his military career resulting in school problems, legal problems, and expulsion from the military on the basis of his "defective attitudes." The examiner stated that it was not possible to differentiate what symptoms were attributable to a specific diagnosis, including personality disorder and dementia, as well as other noted diagnoses, including posttraumatic brain syndrome and polysubstance abuse disorder. Th examiner ultimately opined that adjustment disorders occurred in response to stressful life events, and it is more likely than not that the Veteran's current mental disorder is a separate and distinct condition and more likely than not began prior to his military service and would have persisted at a similar degree regardless of his involvement in the military. In December 2016, the Board noted that the August 2011 examiner did not comment on the Veteran's mood disorder or depression, diagnosed during the appellate period, or offer a sufficient opinion as to any pre-existing acquired psychiatric disorder. A veteran generally is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). This presumption of soundness can be overcome with clear and unmistakable evidence both that a disability preexisted service and was not aggravated by service. Id. As such, the claim was remanded for the RO to afford the Veteran a new VA examination in order to determine the etiology of any acquired psychiatric disorder found present, which was provided in April 2017. During the examination, the Veteran was diagnosed with post-concussion syndrome. The examiner noted the August 2011 VA examinations diagnosing personality disorder, polysubstance dependence, and dementia, and that the Veteran complained of auditory and visual hallucinations while in service that he admitted at the time were an effort to get discharged, and that testing in service was therefore not valid due to the Veteran feigning symptoms. The examiner noted that there was no psychiatric disorder diagnosed on separation from service, and that the 1988 VA in-patient treatment for alcohol dependence and notations that brain injury and PTSD were diagnosed due to a gang-related fight, testing for which was invalid due to overreporting symptoms and exaggeration. The examiner noted that the list of VA-diagnosed disorders included anxiety, opioid dependence, organic mental disorder, substance induced, and post-concussion syndrome, but found that these diagnoses over time were typically on subjective self-reports, and that the objective data available did not support those diagnoses and prior psychiatric testing suggested the Veteran was feigning a mental disorder. The examiner opined that the Veteran did not endorse mental disorder symptoms and there was no objective sign of a mental disorder, and the prior VA examination with objective data did not determine a clinical diagnosis. As the Board noted in its September 2019 remand, however, the examiner in August 2011 did, in fact, provide a diagnosis. Also, the VA examiner in April 2017 declined to diagnose the Veteran with a relevant disorder based on the Veteran's current presentation, one without endorsing mental health symptoms. While the Board considered the examiner's comments as to the lack of valid testing, as well as VA treatment records that detail the Veteran's lack of cooperation and lack of reliability as a historian in the setting of his mental health treatment, the record during the entire appellate period nevertheless indicates the Veteran's significant VA mental health treatment and medication. As such, the Board directed the RO to afford the Veteran a new examination (with an examiner other than the examiner who conducted the April 2017 examination) to attempt to determine the prior psychiatric diagnoses over the course of the appeal and their etiology, to include whether the Veteran had an acquired psychiatric disorder that clearly and unmistakably preexisted service and, if so, was it clearly and unmistakably aggravated during service. In December 2019, a VA examiner diagnosed the Veteran with other specified personality disorder, mild neurocognitive disorder, and other specified trauma and stressor-related disorder. When asked if there was clear and unmistakable evidence that the Veteran's acquired psychiatric disorder preexisted his entry into service, the examiner responded that it was more likely than not that it did. However, she did not consider the appropriate standard or provide adequate rationale, only citing pre-service functioning. When asked if there was clear and unmistakable evidence that the Veteran's preexisting acquired psychiatric disorder was not aggravated during service, she responded that it did not appear that the Veteran's personality disorder was aggravated due to service based on his pre-service and post-service functioning, and that his other specified trauma and stressor-related disorder was aggravated therein due to the cumulative effect of emotional trauma. However, the Board once again found the examiner's opinions to be incomplete, and the claim was again remanded in January 2021 for an addendum opinion. Notably, the examiner did not respond to the inquiry as to whether there was any superimposed injury resulting in additional disability on the Veteran's personality disorder during service, but rather only opined that there was no relationship between the Veteran's diagnosed disorders and his service-connected hearing loss, tinnitus, low back disability, and right ankle disability when asked if such was proximately due to or aggravated by the disabilities. The examiner also opined that the Veteran's mild neurocognitive disorder more likely than not was incurred during service if a traumatic brain injury did occur and depending on the nature and severity of the same. The examiner did not provide rationale for the opinion, which is based on evidence not cited and only appears to surmise that if there was evidence of a traumatic brain injury of an unspecified nature or severity, the Veteran's mild neurocognitive disorder could be attributed to such. Further, the examiner did not discuss the Veteran's in-service and post-service head injuries, or the results of a January 2018 examination specifically related to a separate claim of entitlement to service connection for traumatic brain injury (which was negative for such a diagnosis). Thereafter, an addendum opinion was provided in February 2021, which was again negative. However, while the examiner provided a some rationale for the opinion as to whether any of his acquired psychiatric disorders clearly and unmistakably pre-existed the Veteran's military service and, if so, were clearly and unmistakably not aggravated by that service, absolutely no rationale was provided with the negative opinion regarding secondary service connection whether it was less likely than not that any of his service-connected disabilities caused or aggravated an acquired psychiatric disorder, including hearing loss, tinnitus, low back, and/or a right ankle disability . As such an additional examination is regretfully necessary from an examiner different from those who provided the examination and opinions in December 2019 and February 2021. 2. Service connection for a seizure disorder For similar reasons, the Veteran's seizure disorder claim must also be remanded. During his August 2016 Board hearing, the Veteran asserted that his seizure disorder was incurred seizures during service, stating that while he was lying in his barracks, he had seizures, but did not know what they were and did not seek treatment. He also asserted that he was assaulted during service, hit between the eyes with a baseball bat, and was found unconscious. He reported his post-service treatment for seizures and noted that he was taking two medications to treat such. The Veteran's STRs are silent for complaint, treatment, or diagnosis of any seizures. While the Veteran stated that he did not report his purported in-service seizures, the Board notes that the Veteran did report other ailments during service. As seizure problems are the type that a reasonable person would report while in the military with access to healthcare, if the Veteran was experiencing seizures during service the Board would expect that he would have reported these problems to medical professionals. His STRs do, however, indicate that the Veteran was hospitalized after being assaulted in February 1978. He was initially unresponsive, without focal neurological findings, and physical examination revealed a laceration over the bridge of the nose and abrasions and contusions about the right eye, without other evidence of trauma. There was no acute injury to the jaw, and all findings were within normal limits save for swelling about the lateral malleolus of the right ankle with intact neurology. He was diagnosed with a right ankle disability and concussion. Post-service, the Veteran was admitted for VA treatment for alcohol dependence in February 1988 where reported a blackout during a recent physical altercation and complained of nervousness and headaches. VA treatment records dated in December 2004 indicate that the Veteran was treated for the onset of seizures, thought to be related to withdrawal from prescription medication. In March 2008, a VA treatment provider noted that a neurology consultation revealed what was most likely a complex partial seizure, the last one occurring in November 2005. VA treatment records dated in August 2010 indicate that the Veteran reported an assault, by nine men, three days prior; he presented with multiple contusions and abrasions; computed tomography (CT) was negative. During VA treatment in June 2011, a treatment provider noted that although it would be difficult to prove, he felt that the Veteran had an underlying seizure disorder, likely idiopathic complex partial seizures with secondary generalization, despite non-paroxysmal electroencephalograms (EEGs). During VA psychiatric treatment in September 2013, the provider diagnosed the Veteran, as an Axis III diagnosis, with seizure disorder. Pursuant to the Board's first remand in December 2016, a VA examination was afforded to the Veteran in April 2017 to determine the presence of any seizure disorder during the appeal period and its etiology. After interview and examination, as well as review of the record, the examiner provided the negative opinion that the Veteran's diagnosed disability was less likely than not related to service, explaining that the Veteran's first documented seizure disorder was in December 2004, twenty-five years after service, and his in-service hallucinations were attributed to a psychiatric condition. The examiner reported that there was no evidence of chronic progressive complaints of symptoms referable to seizure disorder from separation from service in 1978 until 2004, and that while the Veteran provided a subjective report of an in-service head injury with loss of consciousness, these were not substantiated in the service treatment records. The examiner further explained that the Veteran's VA treatment records showed multiple instances where he claimed two or three other post-service head injuries associated with a loss of consciousness, and it would be purely speculative to attribute a seizure disorder diagnosis from 2004 to a remote head injury prior to 1978 rather than to one of the more recent head injuries claimed by the Veteran. The Board notes, however, that the February 1978 STR demonstrating the Veteran's in-service assault and resultant hospitalization, with diagnosed concussion, were not associated with the claims file until after the April 2017 examination. As the examiner based the negative etiological opinion on the fact that there was no clinical evidence to support the Veteran's lay report of being assaulted during service with loss of consciousness, the Board remanded the claim again in September 2019 for a new examination, which was afforded in December 2019. The examiner diagnosed the Veteran with idiopathic complex partial seizures with secondary generalization and opined that the Veteran's seizure disorder is less likely than not related to service. The examiner explained that as the post-service treatment records demonstrated multiple episodes of head trauma, beyond once in service, and his seizure disorder did not present itself until twenty-plus years after the Veteran's in-service head injury. It was therefore more medically feasible, the examiner continued, that one of the more recent head trauma events would be the cause of his seizure disorder. It was even more medically likely, the examiner continued, that the Veteran's seizure disorder is idiopathic, i.e., of an unknown cause. The examiner also opined that the Veteran's seizure disorder is less likely than not proximately due to or aggravated by any service-connected disability including hearing loss, tinnitus, a low back disability, a right ankle disability, or any acquired psychiatric disorder, reasoning that there was no medical evidence that the cited disabilities caused or aggravated his seizure disorder. As the Board noted in its most recent remand in January 2021, however, the examiner did not provide rationale for the conclusion that the Veteran's seizure disorder is less likely than not proximately due to or aggravated by any service-connected disability. Also, the Board found that examiner did not adequately consider the Veteran's February 1978 service treatment records, an instead simply concluded that, based on time alone, that it was more appropriate to attribute the Veteran's seizure disorder to his post-service head injuries. Thus, the matter was again remanded for an additional opinion, which was provided in February 2021. However, and while it was provided by a different examiner than the examiner who provided the December 2019 opinion, the addendum opinions are essentially the same as those provided December 2019 that the Veteran's seizure disorder did not present itself until more than 20 years after his one in-service head injury, making it more medically feasible that one of the more recent head trauma events would be the cause, and even more medically likely that it is idiopathic. There was also no rationale provided for the negative opinions regarding secondary service-connected. The examiner's opinions and rationale appear to have been mostly copied from the December 2019 examination report, which suggests that they were not actually based on an independent review of the Veteran's records. As such, an additional opinion is necessary from an examiner different from those who provided the examination and opinions in December 2019 and February 2021. The matters are therefore REMANDED for the following actions: 1. Ask the Veteran to identify all outstanding treatment records relevant to his acquired psychiatric disorder claim. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination, with a VA examiner different than those who provided the December 2019 opinions, to determine the etiology of any diagnosed acquired psychiatric disorder. The examiner is asked to provide opinions as to the following: (a) Whether it is clear and unmistakable (obvious or manifest) that any current psychiatric disorder pre-existed the Veteran's active service. (b) If the answer to (a) is in the positive, whether it is also clear and unmistakable (obvious or manifest) that any current psychiatric disorder was not aggravated by active service beyond its natural progression, considering the Veteran's in-service psychiatric complaints and lay statements describing in-service stress with his family life and disciplinary actions, as well as his lay statements describing a personal assault and February 1978 in-service diagnosed concussion resultant to an assault, as well as the January 2018 VA examination related to his separate claim of entitlement to service connection for traumatic brain injury. (c) If the answer to (a) is in the negative, whether it is at least as likely as not (at least a 50 percent probability) that any current acquired psychiatric disorder had its clinical onset during service or is otherwise related to service, considering the Veteran's in-service psychiatric complaints and lay statements describing in-service stress with his family life and disciplinary actions, as well as his lay statements describing a personal assault and February 1978 in-service diagnosed concussion resultant to an assault, as well as the January 2018 VA examination related to his separate claim of entitlement to service connection for traumatic brain injury (d) Whether it is at least as likely as not (at least a 50 percent probability) that any current acquired psychiatric disorder, including, but not limited to, adjustment disorder is: (1) proximately due to any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability; (2) aggravated beyond its natural progression by any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A complete rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA examination, with a VA examiner different than those who provided the December 2019 opinions, to determine the etiology of any diagnosed seizure disorder. The examiner is asked to provide opinions as to the following: (a) Whether it is at least as likely as not (at least a 50 percent probability) that any current seizure disorder began during active service, or is related to any incident during active service, specifically considering and discussing the Veteran's lay statements of in-service seizure symptoms during service, as well as his recorded in-service psychiatric complaints that included auditory and visual hallucinations, his lay statements of an in-service personal assault wherein he was hit between the eyes with a baseball bat and lost unconscious and his February 1978 in-service diagnosed concussion resultant to an assault, and a January 2018 VA examination related to a separate claim of entitlement to service connection for traumatic brain injury. (b) whether it is at least as likely as not (at least a 50 percent probability) that any current seizure disorder is: (1) proximately due to any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability, or his acquired psychiatric disorder, to include PTSD; (2) aggravated beyond its natural progression by any service-connected disability, including hearing loss, tinnitus, or a low back or right ankle disability, or any current acquired psychiatric disorder. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A complete rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Scarduzio, 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.