Citation NR: 9719966 Decision Date: 06/06/97 Archive Date: 06/13/97 DOCKET NO. 92-05 029 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, including post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, M.A., and G.L.S., M. D. ATTORNEY FOR THE BOARD George E. Guido Jr., Counsel INTRODUCTION The appellant-veteran served on active duty from December 1952 to December 1954. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a March 1990 rating decision of the San Diego, California, Department of Veterans Affairs (VA) Regional Office (RO). CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, applying the benefit-of-the-doubt standard, that he has PTSD, resulting from his military service, that was diagnosed by G.L.S., M.D., who was uniquely qualified as a former Navy psychiatrist and had experience evaluating PTSD. It is asserted that it was not until 1988 or 1989 that the veteran told G.L.S., M.D., about his traumatic train incident in Korea and that the diagnosis of PTSD should be considered under the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (4th ed., 1994) (DSM-IV). Procedurally, it is argued if the Board supplements the record with additional evidence the veteran should be notified and given the opportunity to respond and that it would be prejudicial to the veteran for the Board to deny the case on grounds not considered by the RO. Alternatively, the veteran’s representative requests an independent medical expert opinion under 38 C.F.R. § 20.901(d). And citing provisions of the Veterans Benefits Administration Manual M21-1, Part III, chap. 1. para. 1.03(a), and Part VI, chap. 2, para. 2.10(f) (1996), as equivalent to substantive rules, it is argued that the claim should be remanded for further development if the claim is not well grounded or if VA failed in its duty under 38 U.S.C.A. § 5103(a) to inform the veteran that his application for service-connected benefits was incomplete and that records, or other medical evidence, would be needed to make the claims plausible. DECISION OF THE BOARD In accordance with 38 U.S.C.A. § 7104 (West 1991 & Supp. 1996), after review and consideration of all the evidence and material of record in the veteran's claims file and for the following reasons and bases, the Board decides that the preponderance of the evidence is against establishing service connection for PTSD, that the claim of service connection for dysthymic disorder is not well grounded, and that the claims of service connection for mixed personality disorder with passive-aggressive and antisocial and histrionic features and mixed substance abuse lack legal merit. FINDINGS OF FACTS 1. The veteran did not engage in combat with the enemy and there is no credible supporting evidence that the claimed in- service, noncombat stressors actually occurred. 2. In the absence of credible supporting evidence that the claimed, in-service noncombat stressors actually occurred, there is no complex or controversial medical issue to be resolved. 3. There is no competent medical evidence that links dysthymic disorder to service or to an in-service injury or disease. 4. Mixed personality disorder with passive-aggressive and antisocial and histrionic features is not a disability within the meaning of VA legislation pertaining to compensation benefits. 5. Drug addiction is considered willful misconduct. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1154, 5107(b) (West 1991 & Supp. 1996); 38 C.F.R. § 3.304(f) (1996). 2. The request for an independent medical expert opinion is denied on the grounds that good cause is not shown. 38 C.F.R. §§ 20.901, 20.902 (1996). 3. The claim of service connection for an acquired psychiatric disorder, diagnosed as dysthymic disorder, is not well grounded. 38 U.S.C.A. § 5107(a). 4. Mixed personality disorder with passive-aggressive and antisocial and histrionic features is not a disability for the purpose of establishing entitlement to VA compensation benefits. 38 C.F.R. § 3.303(c) (1996). 5. Drug addiction leading to a diagnosis of mixed substance abuse resulted from the veteran’s willful misconduct and it is not a disability for which service connection can be granted. 38 U.S.C.A. § 105(a) (West 1991); 38 C.F.R. § 3.301(a)-(c)(3) (1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual and Procedural Background The service medical records, including the reports of examinations for induction and separation, are negative for any complaint, finding or history of a psychiatric problem. The records do show that the veteran was hospitalized at the Army hospital at Fort Bliss, Texas, in April 1953 (24 days for acute prostatitis), in May and June 1953 (21 days for anal cryptitis), in August and September 1953 (for 29 days for deviated nasal septum, and in October 1953 (for 14 days nasal deformity). In November 1953 in Tacoma [Washington], a sailor hit him in the jaw. In December 1953, he was assigned to an artillery replacement company. There are two entries in June and November 1954, while he was with the 50th AAA Battalion (Bn), pertaining to an eye evaluation and treatment of diarrhea. The Report of Separation, DD Form 214, discloses that the veteran served in Korea with Battery A, 50th AAA Bn and was awarded the National Defense Service Medal, the Korean Service Medal and the United Nations Service Medal. His duty assignment was unit supply specialist. After service in December 1954, the veteran filed his original application for VA compensation for residuals of anal surgery and a nasal deformity. The service department provided the RO copies of the veteran’s service medical records in January 1955. In a February 1955 rating decision, the RO awarded service connection for anal cryptitis, assigning a noncompensable rating, and denied service connection for nasal deformity. In October 1972, the National Personnel Records Center (NPRC) reported that the available service medical records had been furnished to the RO in January 1955. Copies of records of the Social Security Administration (SSA), dated in February 1987, disclose that the veteran was disabled for Social Security purposes from March 1985. The medical disposition was based on affective disorder and personality disorder. The listed exhibits included a reference to records of a mental health clinic at the University of California, San Diego (UCSD), beginning in March 1985. In a May 1987 statement, the veteran stated that, while in Korea next to the K-13 Air Force Base with the 50th AAA, he started injecting drugs because he was scared and he could not sleep and he was running on nerves. He indicated that he had private quarters in the supply room and he was afraid to talk about his addiction because he did not want a dishonorable discharge. In May 1987 and April 1988, after receiving authorization from the veteran, the RO requested records from G. L. S., M.D. On VA psychiatric examination in June 1987, the veteran stated that he was in the military from around 1952 to 1954. There was no other reference to military service. History included drug abuse, but he had not used drugs for 20 years. The diagnoses were major depression, mixed substance abuse by history, in remission, and mixed personality disorder with schizotypal and histrionic features. In a July 1987 rating decision, the RO awarded the veteran nonservice-connected pension benefits on the basis of the June 1987 report of VA psychiatric examination. The RO found the nonservice-connected disability of major depression to be totally disabling. In a September 1987 rating decision, the RO found the veteran incompetent for VA purposes. In statements in April 1988 and February 1990, the veteran’s spouse reported that according to the veteran he saw a psychiatrist in Suwan, Korea, because he could not sleep and he was given private quarters because he had problems adjusting to life there. She indicated that a friend of the veteran was shot and killed on a train ride from Pusan to Suwan, Korea, causing fear in the veteran who found that drugs lowered his level of fear. In a May 1988 rating decision, the RO denied the veteran’s initial claim of service connection for a nervous (psychiatric) disorder, major depression. After the RO notified the veteran of the adverse determination and of his procedural and appellate rights, he did not appeal the decision and the rating decision became final. The current appeal began in February 1990, when the veteran applied to reopen his claim of service connection for a psychiatric disorder. In March 1990 rating decision, the RO held that new and material evidence had not been presented to reopen the claim. The veteran filed a Notice of Disagreement in September 1990. The RO furnished the veteran a Statement of the Case in October 1990. The veteran filed his Substantive Appeal in February 1991. The additional evidence consisted of several lay statements, testimony from the veteran and witnesses, a statement from the veteran, and an opinion from G.L.S., M.D. A summary of which follows. The lay statements were: The veteran said on the first day in Korea a friend was killed on a train ride and he experienced a lot of fear (August 1990 statement of A. F., a friend since 1965); the veteran told me in December 1954 that he started drug use in Korea out of fear and he was very anxious, nervous and disturbed (August 1990 statement of A. R., a life-long friend); the veteran’s personality was drastically different when he returned from Korea and he seemed spaced-out and withdrawn (November 1990 statement of the veteran’s sister); the veteran visited after service and he lived in his car for years (September 1990 statement of D. R.); the veteran was on dope when he came back from Korea (September 1990 statement of C. R., a friend of the veteran’s parents); the veteran was very disturbed by his Korean experiences when he returned home (September 1990 statement of D. D., American Legion representative); and, the veteran came back from Korea a different person with a lot of problems and he was nervous and depressed (March 1991 statement of M. A., who knew the veteran before he went to Korea). At a hearing in July 1991, M. A., a friend of the veteran since the 1940s, testified that after Korea the veteran was anxious, he did not talk much and he was not the same. He also testified that he did not ask the veteran about his Korean experiences. At the July 1991 hearing, G.L.S., M.D., the veteran’s treating psychiatrist, stated that he was a Navy psychiatrist during Vietnam. He testified that he has been treating the veteran for about ten years and that the veteran initially presented with symptoms of anxiety and depression. He expressed the opinion that the veteran had PTSD that began in the Army in Korea. He referred to the veteran’s fear that was generated from the veteran’s observation of casualties after he entered the Army and from his assignment to Korea as a regular soldier rather than assignment to the medical corps or to entertaining troops as he expected. G.L.S., M.D., also testified that the veteran apparently saw a psychiatrist because of his state of agitation and general psychological problems and that arrangements were made for the veteran to have individual sleeping quarters. At the same hearing, the veteran testified that during basic training at Fort Bliss, Texas, he was hospitalized a few times for surgery and he helped on the ward where he saw a lot of casualties from Korea that made him not want to go to Korea. He testified that he thought he was going to the medical corps or special services as an entertainer and that orders were cut for the medical corps, but he was sent to Korea, where he had a difficult time adjusting. He stated that he went to sick call a couple of times because he could not sleep and he was tired and then he was assigned to semi- private sleeping quarters in a supply room and he became a supply clerk. He related that he thought the person he saw at sick call was a psychiatrist because he asked questions about his wife (the veteran was not married), mail and religion. The veteran also testified that on a train from Pusan he was talking to a fellow in the back car and when he went to the front car there was a shot through the window and he thinks that the fellow he had been talking to had been shot. He did not know whether the fellow died and after that he used drugs to get through everything. He testified that he was never in the front and he was a supply clerk. He stated that after service he did not seek help until he went to SYNANON. In a March 1992 statement, the veteran elaborated on his July 1991 testimony. He indicated that the orders for the medical corps were intended to keep him stateside because he was fearful of being hurt in Korea. As for the train incident, he referred to the fellow as a G.I. who had been sitting next to him before he was shot. He also stated that when he was assigned to the 50th AAA he had trouble sleeping and relating from the first day, that he saw a chaplain who sent him to sick call to see a doctor, perhaps a psychiatrist, who helped him get separate sleeping quarters, and that he found comfort in drugs, but drug use added to his anxiety and guilt. He stated that after service he was anxious and nervous and drifted until 1972 when he entered SYNANON for drug detoxification. He also stated that it was over ten years previously that he found G.L.S., M.D., who helped him understand what happened to him in service. In a March 1992 statement, G.L.S., M.D., expressed the opinion that the veteran suffered from chronic post-traumatic stress syndrome that began when he was a soldier during the Korean conflict. When the appeal was first before the Board in March 1993, the Board found the evidence new and material to reopen the claim of service connection for a psychiatric disorder, including PTSD. The Board then remanded the matter to the RO for further development to include a search for additional service medical and administrative records, to obtain medical records associated with the veteran’s SSA disability claim and the treatment records of G.L.S., M.D., to have the veteran provide detailed information (who, what, when and where) of each in-service stressor, and, if appropriate, the information was to be forwarded to the U. S. Army & Joint Services Environmental Support Group (ESG) for verification, to arrange for a VA social and industrial survey and an examination by a board of VA psychiatrists for a diagnosis in accordance with the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 247 (3rd ed. rev. 1987) (DSM-III-R). A summary of the additional evidence follows. Copies of records of UCSD disclose that in March 1985 the pertinent diagnoses were inhibited sexual desire, polysubstance abuse in remission, and rule out paranoid/antisocial personality disorder. Copies of SSA records disclose that in a supplemental report, transcribed in August 1986, G.L.S., M.D., criticized three other psychiatric evaluations conducted in 1985 in conjunction with the veteran’s claim for SSA disability benefits. He specifically disagreed with one physician’s characterization of the veteran as an antisocial personality. He also found inadequate the evaluation of a second physician who had noticed that the veteran had inappropriate and excessive smiling and mild euphoria, but did not explore with the veteran visual hallucinations. As for the third evaluation, he questioned the diagnosis of passive-dependent with manipulative traits. In the opinion of G.L.S., M.D., the diagnosis was schizotypal personality disorder, basically, because of bizarre thought content, hallucinatory experiences, idiosyncratic thought processes, reclusiveness, magical thinking, paranoid ideation and depression. There is not a single reference to the veteran’s military service. Copies of other SSA documents disclose that the veteran had a long history of mental problems, but the treating physician’s file was insufficient to evaluate the veteran’s mental impairment, necessitating a psychiatric consultation. The reported diagnoses were bipolar affective disorder (May 1985), antisocial personality (August 1985), substance abuse and character disorder (June 1986), and dysthymic disorder (September 1986). In February 1987, an administrative law judge for SSA found that the medical evidence established that he veteran had depression, suicidal ideation, paranoid thoughts and anxiety. In an April 1993 statement, G.L.S., M.D., stated that the following information was obtained from the veteran, from documentation provided to him and from his own observations. G.L.S., M.D., indicated that the veteran saw many war injuries while he hospitalized for surgery and that when the veteran got to Korea he saw a fellow train passenger’s head blown off by North Korean gun fire. He stated that these things along with his general psychiatric problems set in motion PTSD. He reported that the veteran had traumatic re- experiencing of the traumatic events with nightmares, increased arousal, anxiety with startle responses, and avoidance of reminders of dismemberment, noise of battle and explosion of a man’s head. In addition, the veteran had flashbacks and he self-medicated and became a drug addict. He expressed the opinion that the veteran’s PTSD was service- related as it was not present before service, the traumatic events involved were part of service, and it was clearly present by the time his service was completed. Attached to the statement was the physician’s impressive Curriculum Vitae. In an April 1993 statement, identifying the in-service stressors, the veteran recounted his experiences at Fort Bliss, Texas, where he was hospitalized for surgeries and where he saw veterans from Korea who were missing limbs that made him depressed and fearful about Korea. He related that the G.I. he was sitting next to on the train was shot in the head as soon as he, the veteran, got up to go to the forward car. He stated that with assignment to the 50th AAA he could not relate to anyone and he was afraid of everything and he had separate sleeping quarters in the supply room where he worked. In February 1994, the veteran was seen by VA for a personality assessment. He was unable to complete the assessment and the information could not be used to aid in a diagnosis. On psychosocial examination by VA in February 1994, there was a 42 year psychiatric history with no hospital admissions. History included service as a supply clerk and in Korea, where he witnessed a fellow serviceman being shot on a troop train. The impression was inadequate, dependent personality. In August 1993, March 1994 and July 1994, NPRC reported that this was a fire related case and no personnel or medical records were recovered from the fire in July 1973 and no Surgeon General records were found. NPRC also reported that a negative search of the morning reports for Battery A, 50th AAA Bn, from January to March 1954. On VA psychiatric examination in March 1994 conducted by a board of two psychiatrists, it was noted that the veteran saw Dr. C. for medication and that G.L.S., M.D., had diagnosed PTSD. According to the veteran, he served in Korea for a year as a clerk typist in the back lines away from combat. He felt PTSD began during the Korean conflict, when on a bus [sic], after leaving his seat, the man who had been sitting near him was shot and later died. The veteran stated that he had nightmares about the incident. He also described as traumatic a morbid fear of going to Korea and he saw men with amputations and other shocking wounds from Korea while he was hospitalized. There was a long history of drug addiction from the veteran’s time in Korea until 1978. Subjectively, there were symptoms of difficulty sleeping, irritability, isolation, withdrawal, hypervigilence, startle response, detachment and estrangement, but he had feelings of love for his spouse and son. There was, however, no clear cut survivor’s guilt, avoidant behavior or flashbacks. The examiners found the veteran evasive and inconsistent on answering questions. He was not significantly depressed, hypervigilant or anxious. He was a little over dramatic and histrionic. The diagnoses were dysthymic disorder, mixed substance abuse by history and in remission by history, and mixed personality disorder with passive-aggressive, antisocial and histrionic features. In the examiners’ opinions, the veteran did not meet the diagnostic criteria for PTSD because the symptoms were not sufficiently clear or consistent enough. In their judgments the veteran had deep-seated character pathology, resulting from childhood, that made him stress sensitive during the first few weeks of basic training. In their opinions the shooting incident and the viewing of unsettling war injuries were not severe enough in a normal non-predisposed person to cause the kind of damage the veteran ascribed to them or sufficiently devastating to cause the veteran’s lifelong maladjustment pattern. After the Board’s remand in March 1993 and after the requested development was completed, the RO adjudicated the claim in January 1996. In adjudicating the claim, the RO also found the veteran competent for VA purposes. In the January 1996 Supplemental Statement of the Case, the RO notified the veteran that there was no additional evidence that warranted submission of the alleged stressors to ESG for verification. In July 1996 the record was supplemented with copy of a DAV magazine article, PTSD: Treating the Trauma Of War (January 1992), and copies of photographs of the veteran prior to service and during basic training. In July 1996, the veteran’s son reported that G.L.S., M.D., had died in May 1993 and that they were going to ask the South Korean government to check the logs of the government- owned railroad to confirm the event the veteran experienced in the early fifties. In November 1996, he reported that the letter from the Korean National Railroad was not helpful. In September 1996, the Board again remanded the matter to the RO for a de novo review of all the evidence of record, applying 38 C.F.R. § 3.304(f) (pertaining to the evidentiary requirements for establishing service connection for PTSD). After conducting the de novo review, the RO, in a December 1996 rating decision, denied the claim of service connection for an acquired psychiatric disorder, including PTSD, the matter now before the Board for appellate review. In the December 1996 Supplemental Statement of the Case, the RO notified the veteran that service connection for PTSD was denied on the grounds that there was no clear diagnosis of PTSD with credible supporting evidence that the claimed in- service stressors actually occurred and a link, established by medical evidence, between current symptomatology and the claimed in-service stressors. The RO also notified the veteran that service connection for dysthymic disorder was denied on the grounds that it was not incurred in service or until many years after service, that service connection for mixed personality disorder was denied on the grounds that it was not a disability subject to service connection, and that service connection for substance abuse was denied on the grounds that it was the result of the veteran’s own willful misconduct. II. Analysis A. Well-Grounded Claim Under 38 U.S.C.A. § 5107(a), a person claiming entitlement to VA benefits has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The United States Court of Veterans Appeals (Court) has defined a well-grounded claim as a "plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of [section 5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded service-connection claim generally requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and a current disability. Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff’d per curiam 78 F.3d. 604 (Fed. Cir. 1996) (table). For the purpose of determining whether a claim is well grounded, the evidence is presumed to be credible. King v. Brown, 5 Vet.App. 19, 21 (1993). Where the determinative issue involves either medical etiology (such as with respect to a nexus between a current condition and an in-service disease or injury) or a medical diagnosis (such as with respect to a current disability), competent medical evidence is generally required to fulfill the well-grounded-claim requirement of § 5107(a) that the claim be “possible” or “plausible”. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). B. PTSD 1. Changes in the Law During the Pendency of the Appeal During the pendency of this appeal 38 C.F.R. § 3.304 was amended, effective in May 1993, to include subsection (f), pertaining specifically to PTSD service-connection claims. Prior to the May 1993 amendment, PTSD claims were governed by provisions of the VA Adjudication Procedure Manual M21-1 [hereinafter M21-1], Subchapter XII, para. 50.45 (Jan. 25, 1989), that required essentially the same elements that were incorporated in 38 C.F.R. § 3.304(f). Subsequently, the M21- 1 provisions were amended to reflect the PTSD requirements set forth in 38 C.F.R. § 3.304(f). See M21-1, Part VI, para. 7.46 (first sentence) (Oct. 11, 1995) and currently and unchanged at M21-1, Part VI, para. 11.38 (first sentence) (Aug. 26, 1996). As a general rule, the veteran is entitled to have his claim adjudicated under whichever regulatory or M21-1 provision would be more favorable to him in light of the regulatory change while his case was on appeal to the Board. See Karnas v. Derwinski, 1 Vet.App. 308, 312-13 (1991). Also the Court has previously held that the M21-1 provisions of para. 7.46, pertaining to PTSD, were substantive rules and the equivalent to VA regulations. The adoption of 38 C.F.R. § 3.304(f) in May 1993 moots the M21-1 provisions regarding PTSD adjudications except where the M21-1 is more favorable to the veteran. Also during the pendency of this appeal, effective November 7, 1996, VA amended several sections of the Schedule for Rating Disabilities in order to update the portion of the Rating Schedule, pertaining to mental disorders, and, in part, to conform with changes with the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV), replacing the 1980 3rd edition of DSM (DSM-III) and the 1987 revised 3rd edition DSM (DSM-III-R). 61 Fed. Reg. 52,695 (1996) (to be codified at 38 C.F.R. Part 4, §§ 4.125 to 4.130). Under DSM-IV, the diagnostic criteria for PTSD, in pertinent part, shifts from an objective standard (seen in DSM-III-R) in assessing whether a stressor is sufficient to trigger PTSD as subjective standard. The November 1996 amendment has not changed the requirements of 38 C.F.R. § 3.304(f) and the M21- 1 provisions continue to apply the criteria set forth in DSM- III-R. The version of DSM most favorable to the veteran applies. In Cohen v. Brown, No. 94-661, slip op. at 14-20 (U. S. Vet. App. Mar. 7, 1997), the Court held that the DSM diagnostic criteria cannot be read in a manner that would add requirements over and above the three primary elements set forth in 38 C.F.R. § 3.304(f). Accordingly, the applicable DSM criteria come directly into play for adjudication only when there is a medical opinion as to a current PTSD diagnosis and a nexus of current symptomatology to a claimed in-service stressor -- two of the three PTSD elements under 38 C.F.R. § 3.304(f). At that point, the applicable DSM criteria may be used only as the basis for a return of the examination report to the RO for clarification or further examination, and such a return is mandated when the Board believes that the report does not accord with the applicable DSM diagnostic criteria. The version of DSM most favorable to the veteran applies. The Court also discussed the diagnostic criteria of PTSD under DSM-III-R and DSM-IV, which is referred to below. 2. Applying the Law to the Facts On the facts of this case, the Board finds that the veteran satisfied his initial burden of submitting a well-grounded PTSD claim because he has submitted medical evidence of current disability (March 1992 report of G.L.S., M.D. who expressed the opinion that the veteran suffered from PTSD); lay evidence (the veteran’s lay statements and sworn hearing testimony relating to stressors during service, presumed credible for the purpose of establishing a well-grounded claim); and, the opinion of G.L.S., M.D., who stated that the veteran’s PTSD began when he was a soldier during the Korean conflict (March 1992 report). Adjudication of a well-grounded claim of service connection for PTSD requires the evaluation of the evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran’s military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). In addition section (f) of 38 C.F.R. § 3.304, pertaining to the adjudication of PTSD claims, provides that: Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in- service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in service stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in- service stressor. The award of service connection for PTSD, therefore, requires the presence of three elements: (1) a current, clear medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and, (3) medical evidence of a causal nexus between current symptomatology and the specified claimed in-service stressor. In this case, the veteran does not argue that he has a combat-related stressor (he was never in the front, July 1991 hearing testimony and he was in the back lines away from combat, March 1994 report of VA examination). And there is no service department evidence (His duty assignment was unit supply specialist and his individual decorations of the National Defense Service Medal, the Korean Service Medal and the United Nations Service Medal are not conclusive evidence of a stressor during combat under 38 C.F.R. § 3.304(f)) that the veteran was in combat. And there is no other source of evidence either suggesting or depicting the veteran in combat as the lay statements do not contain any such accounts. For these reasons, the Board finds that the preponderance of the evidence is against finding that the claimed, in-service stressors were related to combat. The veteran, however, does describe noncombat-related stressors, namely, (1) a fear of Korea generated in the context of his orders to Korea when he thought he might receive an assignment to the medical corps stateside or to special services as an entertainer, his stateside observance of hospitalized Korean conflict casualties, and a difficult adjustment once in Korea, where he saw a chaplain and went to sick call and where he was assigned to separate sleeping quarters in a supply room [hereinafter referred to as fear of Korea]; and (2) the train incident in Korea in which a passenger was shot [hereinafter referred to as the train incident]. The veteran has testified to these noncombat-related stressors (July 1991 hearing) and he has referred to the noncombat related stressors in other documents (veteran’s March 1992 and April 1993 statements) and he has related them to G.L.S. M.D., (April 1993 report of G.L.S., M.D.) and to VA physicians (March 1994 report of VA examination). As for the veteran’s testimony and his other statements regarding the noncombat-related stressors, where as here the claimed stressors are not combat-related, a veteran’s lay testimony regarding the in-service stressors is insufficient to establish the occurrence of the stressor and must be corroborated by credible supporting evidence that the claimed stressors actually occurred. Cohen v. Brown, supra at 20 (citing Doran v. Brown, 6 Vet.App. 283, 289 (1994)). Again, the only other supporting evidence consists of several lay statements none of which provides a personal account of the alleged events that occurred in service. As for the July 1991 testimony and the April 1993 medical opinion of G.L.S., M.D., relating to the diagnosis of PTSD in which the physician recites the noncombat stressors of fear of Korea and the train incident, this does not qualify as the requisite corroborating evidence of a stressor. In Moreau v. Brown, 9 Vet.App. 389, 396 (1996), the Court held that credible supporting evidence of the actual occurrence of an in-service stressor cannot consist solely of after-the-fact medical nexus evidence. In other words, neither the veteran’s testimony nor the medical opinion of G.L.S., M.D., establishes that the claimed, noncombat-related stressors actually occurred. Moreover, the claimed stressors of fear of Korea and the train incident are anecdotal incidents and are not researchable by ESG. In order to be researched by ESG incidents must be reported and documented and ESG can verify only specific combat incidents as recalled by the veteran, who must provide the who, what, where and when of each stressor. Cohen v. Brown, supra at 5-6, citing ESG guidelines for PTSD claims. As for the train incident, the veteran’s son reported that an attempt to verify the train incident with the Korean National Railroad was not helpful. As for documentation of sick call visits while the veteran was in Korea, the RO obtained copies of the veteran’s service medical records in January 1955, before the fire at NPRC in 1973, and they contained two entries in June and November 1954 unrelated to the claimed stressors. The RO also made a request to NPRC in 1972, before the 1973 fire, and the response was that the available service medical records had been furnished to the RO in January 1955. Lastly in 1994, NPRC could not find Surgeon General records or pertinent unit morning report entries. Without credible supporting evidence that the claimed in- service noncombat-related stressors actually occurred, the diagnosis of PTSD by G.L.S., M.D., on the merits, considering all the evidence of record and beyond that which is required of a well-grounded claim, does not establish a current, clear medical diagnosis of PTSD and the diagnosis is not persuasive medical evidence of a causal nexus between current symptomatology and the claimed, but unsubstantiated, in- service stressors. As for the March 1994 medical opinion of the board of VA psychiatrists, they found that the veteran did not meet the diagnostic criteria for PTSD, assuming the stressors actually occurred, because the shooting [train] incident and the viewing unsettling war injuries were not severe enough in a “normal non-predisposed person”. Clearly, the VA psychiatrists were applying an objective standard under DSM- III-R as requested in the Board’s March 1993 remand, that is, the person has experienced an event that is outside the range of usual human experience that would be markedly distressing to almost anyone. The remaining question is whether the board of VA psychiatrists would change their opinion under the subjective diagnostic criteria of DSM-IV, a version more favorable to the veteran, as it provides that the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to physical integrity of self or others. While the sufficiency of the stressor is a medical determination, the existence of the stressors is a factual question within the Board’s purview. See West v. Brown, 7 Vet.App. 70, 79-80 (1994). In this case, the Board has already determined that there is no credible supporting evidence that the claimed in-service noncombat-related stressors actually occurred. Stated differently, there is no credible supporting evidence that the claim in-service, noncombat-related stressors actually occurred to predicated a diagnosis of PTSD under either the objective diagnostic criteria of PTSD of DSM-III-R or the subjective diagnostic criteria of DSM-IV. In light of the above, there is not an approximate balance of positive and negative evidence to which the benefit-of-the- doubt standard applies as the lay statements, the veteran’s testimony and statements and the testimony and medical opinion of G.L.S., M.D., have been factually or legally insufficient to establish the actual occurrence of in-service noncombat-related stressors to establish a clear diagnosis of PTSD. In the absence of evidence of a current, clear medical diagnosis of PTSD, credible supporting evidence that the claimed in-service noncombat stressors actually occurred, and medical evidence of a causal nexus between current symptomatology and the claimed, but unsubstantiated, in- service stressors, the preponderance of the evidence is against the claim of service connection for PTSD, applying 38 C.F.R. § 3.304(f). Without credible supporting evidence that the claimed in- service noncombat-related stressors actually occurred, there is no identifiable complex or controversial medical issue to be determined such as the sufficiency of the stressors. In the absence of a good-cause showing, the request for independent medical expert opinion is denied. C. Dysthymic Disorder A well-grounded service-connection claim requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and a current disability. Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff’d per curiam 78 F.3d. 604 (Fed. Cir. 1996) (table). Where the determinative issue involves either medical etiology (such as with respect to a nexus between a current condition and an in-service disease or injury) or a medical diagnosis (such as with respect to a current disability), competent medical evidence is generally required to fulfill the well-grounded-claim requirement of § 5107(a) that the claim be “possible” or “plausible”. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). Against this background the Board must decide whether the evidence satisfies the requirements for a well-grounded claim for dysthymic disorder. The service medical records are negative for any compliant, finding or history of dysthymic order. After service, an acquired psychiatric disorder was first diagnosed in May 1985 (bipolar disorder, SSA records). In June 1986, dysthymic disorder was diagnosed as shown in SSA records. VA diagnosed major depression in June 1987 and then dysthymic disorder in March 1994. Not one of the reports contained medical evidence of a nexus between an in-service injury or disease and the post-service acquired psychiatric disability, most recently diagnosed by VA as dysthymic disorder. In the absence of competent medical evidence to support a link between service and the post-service dysthymic disorder, the claim is not well grounded. As for the lay statements that: The veteran experienced a lot of fear (August 1990 statement of A. F., a friend since 1965); he was very anxious, nervous and disturbed (August 1990 statement of A. R., a life-long friend); his personality was drastically different when he returned from Korea and he seemed spaced-out and withdrawn (November 1990 statement of the veteran’s sister); he was very disturbed by his Korean experiences when he returned home (September 1990 statement of D. D., American Legion representative); and, he came back from Korea a different person with a lot of problems and he was nervous and depressed (March 1991 statement of M. A., who knew the veteran before he went to Korea), are relevant. Presuming these statements to be true for the limited purpose of determining whether the claim is well grounded, lay persons can certainly provide an eye-witness account of the veteran’s symptoms as they perceived them. However, the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge, that is, that these symptoms were manifestations of dysthymic disorder. The lay statements alone do not make a well-grounded claim as the significance of the observed symptoms involves a medical diagnosis and lay persons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). For these reasons, the claim pertaining to dysthymic disorder is not well grounded. In the December 1996 Supplemental Statement of the Case, the RO notified the veteran that service connection for dysthymic disorder was denied on the grounds that it was not incurred in service or until many years after service. In the precedent opinion, Meyer v. Brown, 9 Vet.App. 425, 431-432 (1996), the United States Court of Veterans Appeal (Court) held that when the RO does not specifically address the question of whether the veteran’s claims for service- connected benefits are well grounded but rather, as here, proceeds to adjudicate on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded claim analysis. On the authority of the precedent opinion in Meyer, binding on VA, the Board, while finding the claim not well grounded, holds that the veteran was not prejudiced by any lack of notification in the SSOC as to the law regarding a well-grounded claim. The Court also held that VA is not required under the statutory duty to assist, 38 U.S.C.A. § 5107(a), to seek further development in the absence of a well-grounded claim. Meyer at 433-34. As for the duty to inform under 38 U.S.C.A. § 5103(a) (West 1991 & Supp. 1996), in Meyer at 429-430, the Court held where a claimant has not submitted a well-grounded claim and VA is on notice that relevant evidence may have existed, or could have been obtained, that, if true, would have made the claim plausible, and that such evidence has not been submitted with the application, then the application is incomplete and VA has the obligation under 38 U.S.C.A. § 5103(a) to notify the claimant of the evidence necessary to complete the application. In this case, the veteran has not identified any existing, relevant evidence, that, if true, would have made his claims plausible. For this reason, VA has not failed in its to duty under 38 U.S.C.A. § 5103(a) to inform the veteran of the evidence necessary to complete his application for service- connected benefits. To the extent that the Manual M21-1 provisions may be in conflict with the Court’s ruling in Meyer, they are void. D. Mixed Personality Disorder E. Mixed Substance Abuse Under 38 C.F.R. § 3.303(c), personality disorders are not diseases within the meaning of applicable legislation pertaining to compensation benefits. Under 38 C.F.R. § 3.301(a), direct service connection may be granted only when a disability was incurred or aggravated in line of duty and not the result of the veteran’s own willful misconduct. However, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. 38 C.F.R. § 3.301(c)(3). Therefore, the veteran is not entitled to VA compensation under the law for either mixed personality disorder or for mixed substance abuse. ORDER Service connection for an acquired psychiatric disorder, including dysthymic disorder and PTSD, is denied. There is no entitlement to compensation under VA law for either mixed personality disorder or mixed substance abuse. RONALD R. BOSCH Member, Board of Veterans' Appeals 38 U.S.C.A. § 7102 (West Supp. 1996) permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1996), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -