Citation Nr: 0000871 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 94-36 760 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a right knee disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Michael A. Holincheck, Associate Counsel INTRODUCTION The veteran served on active duty from January 1971 to May 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1991 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The veteran's case was remanded for additional development in June 1996. During the pendency of the remand, the veteran relocated to Tennessee and his claims file was transferred to the RO in Nashville, Tennessee. FINDINGS OF FACT 1. The veteran is not credible. 2. The overwhelming preponderance of the evidence shows that any diagnosed psychiatric disorder, to include PTSD, is not related to service. 3. Without considering the issue of credibility, the claim of entitlement to service connection for a right knee disability is not supported by cognizable evidence demonstrating that the claim is plausible or capable of substantiation. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder, to include PTSD, was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1999). 2. The claim of entitlement to service connection for a right knee disability is not well grounded. 38 U.S.C.A. § 5107. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for an Acquired Psychiatric Disorder, to include PTSD As a preliminary matter, the Board finds that the veteran's claim is well-grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the veteran is found to have presented a claim which is not inherently implausible. Furthermore, after examining the record, the Board is satisfied that all relevant facts have been properly developed in regard to the veteran's claim and that no further assistance to his is required to comply with the duty to assist, as mandated by 38 U.S.C.A. § 5107(a). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In addition, certain chronic diseases, including psychoses, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Moreover, service connection for PTSD requires medical evidence establishing a diagnosis of the condition; a link, established by medical evidence, between current symptomatology and the claimed in-service stressor; and, credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (1999). There is no evidence of record to show that the veteran engaged in combat during service or the alleged stressor is related to combat. Accordingly, the veteran's lay testimony, by itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, there must be credible supporting evidence that the stressor actually occurred. Credible supporting evidence is not limited to service department records, but can be from any source. See YR v. West, 11 Vet. App. 393, 397 (1998). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b) (1999). The chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the Court, lay observation is competent. If chronicity is not applicable, a claim may still be well grounded on the basis of 38 C.F.R. §3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). The veteran alleges that he suffers from PTSD, or another acquired psychiatric disorder, as a result of incidents in service. Specifically, he maintains that he suffered continual harassment, to include physical assaults, as a result of being Jewish while on active duty. A review of the service medical records (SMRs) reveals that the veteran was referred for a consultation with psychiatry in May 1971. The SF 513 indicated that the veteran was depressed about his chronic inability to stop telling untruths. He was a security policeman and had had thoughts of doing away with himself. The veteran was admitted for a psychiatric evaluation. An entry dated May 4, 1971, noted that the appellant had thoughts of suicide but did not pull his gun out of its holster, because he was Catholic and could not go through with it. A discharge summary noted that the veteran had had difficulty with his girlfriend and had become depressed. He had lied to his first sergeant about needing to return to his home. The veteran improved after his relationship with his girlfriend improved. He was diagnosed with acute, moderate adult situational reaction. He was also diagnosed with a long-standing passive-aggressive, passive-dependent personality style. A final note indicated that should the veteran experience further difficulty with respect to depressive symptoms or suicidal ideation, it was recommended that he be administratively separated as soon as possible. The veteran was then sent to Germany to participate in a military exercise. He suffered bilateral heel fractures in September 1971 when he jumped from a height of 10 feet. The veteran incurred no other physical injury. He was initially treated in Germany, and then medevaced back to the United States. There were a number of documents associated with the veteran's return to the United States which listed his religious preference as Catholic. Finally, in December 1971, the veteran was again placed in an inpatient status for psychiatric evaluation. The hospitalization followed after the veteran threatened another security policeman with a weapon on two occasions and struck him on another occasion. The discharge summary reflects that the other person reportedly taunted the veteran persistently with claims that he had had sexual relations with the appellant's new fiancée. This fiancée proved to be a woman who was still married. Interestingly, while hospitalized the veteran began dating and became engaged yet a third time almost immediately. The veteran's discharge diagnosis was acute, moderately severe anxiety neurosis, manifested by dissociated reaction, anxiety, somewhat impaired objective relationships. He was noted to have a predisposition to a mild, somewhat immature personality pattern. A medical board was recommended. The veteran was discharged by reason of an anxiety neurosis, and awarded severance pay. The veteran later enlisted in the Ohio Air National Guard. There are two physical examination reports from this term, one from February 1975, and the other dated in May 1976. In February 1975, he purportedly reported that he was treated inservice for a nervous disorder that "no longer exists." He was discharged from the Guard in April 1978 for excessive absence from military duty. At no time was a psychiatric disorder diagnosed. The veteran originally sought to establish service connection for an acquired psychiatric disorder in January 1987. He did not specify a particular diagnosis. Associated with the claims file at that time were VA treatment records for the period from January 1986 to February 1987 and a hospital summary for the period in October 1986. He reported that he was Catholic. The hospital summary reflects that the veteran falsely reported that he was "service-connected" for a nervous disability. He complained of a six to seven month history of feeling depressed and on edge. Among some of the other "symptoms" endorsed by the veteran were recurrent recollections of his "Vietnam experience." He felt that his wife's difficulty in dealing with his "Vietnam experiences" partially resulted in their separation and pending divorce. It came to the attention of the veteran's doctors that he had several legal charges pending against him and he was turned over to the local police. The discharge diagnosis was malingering. The treatment records reflect that he was seen in the mental hygiene clinic (MHC) in January and February 1987. He said that he got married in 1981 and divorced in December 1986, while he was in jail. He indicated that he was a compulsive spender. He was diagnosed with a personality disorder, and recurrent depression. Also associated with the claims file are VA treatment records for the period from March 1990 to June 1991. The veteran was hospitalized in September and October 1990. He reported that he was a compulsive liar, and he gave a history of discharge from the military for depression in 1972. He also related having been married three times, with the first two marriages ending by mutual agreement. One former wife related that some of the appellant's past lies included being in Vietnam with the Green Berets and of inheriting large sums of money. He had never told her of his second wife and had denied having any children although he had a 13 year old son by his first wife. When the veteran was confronted with the lies he became remorseful. He claimed that he lied so that people would not get to know him and out of a fear of rejection. He claimed he would never do it again. The Axis I diagnoses were major depression and dysthymia. He was diagnosed on Axis II with a mixed personality disorder (anti-social and passive-aggressive traits). A MHC progress note entry, dated October 12, 1990, noted that the veteran was married four months earlier and was a stepfather to two children. He was planning to start a new job. There was no indication of any thought disorder, or ideas of homicide or suicide. Subsequent entries dated in November and December 1990 reflected that the veteran was increasingly anxious and having a difficult time coping with his responsibilities. He had been unable to secure a debt consolidation loan and was fearful of informing his wife. In February 1991 he was diagnosed with dysthymia and inadequate personality. A MHC entry, dated February 22, 1991, noted that the veteran's was having difficulty with his paycheck from work and that checks for several co-workers had bounced. He tried to explain this to his wife but was afraid that she did not believe him. He acknowledged that his behavior of lying "about almost everything" had changed since his hospitalization (September to October 1990). Subsequent MHC entries detailed additional family problems and attempts to resolve them. The veteran submitted VA records in support of his claim in July 1992. The first record was a copy of discharge instructions for a period of hospitalization with a discharge in November 1991. The diagnoses listed were: cyclothymia, PTSD by history, generalized anxiety disorder with depressed mood, and rule out double depression. He also submitted an interim summary from the VA medical center (VAMC) in Dayton, Ohio, dated in June 1992. The summary was written by a VA psychiatrist, hereafter referred to as the veteran's VA physician. The summary indicated that the veteran had been an inpatient since October 1991 because of depression and nightmares. He was discharged from the psychiatric unit to the local VA domiciliary. His nightmares involved his life experiences which included difficulties with his wife, and the amputation of the distal phalanges of his index and middle fingers of the right hand. The summary listed the veteran's diagnoses as: PTSD, noncombat related; a generalized anxiety disorder with mixed emotional features; alcohol abuse, in remission; major depression by history; and, intermittent explosive disorder with impulsivity. In October 1992, the veteran, using VA Memorandum stationery, submitted a MHC progress note entry dated in August 1992. The entry merely noted that the veteran had been depressed the previous two weeks. There was no attribution of the symptoms or a diagnosis to any incident of service. In November 1992, while a patient at a VA medical center, the appellant submitted a multi-page "addendum" to the June 1992 interim summary. However, in light of the multiple misspellings and style used in the document there is significant doubt that the treating physician prepared the statement or signed it. Therein the veteran was reported as having been harassed during basic training because he was Jewish. He was reportedly verbally harassed and made to do more than his share of chores, and subjected to anti-Semitic remarks. The appellant said that the abuse continued at his first duty station, to include an incident where several comrades held him down, poured alcohol into his mouth, and then forcefully threw him down some stairs. Allegedly they too made anti-Semitic remarks at the time of the assault. He said that he reported the incident but was told to live with it or get out of the service. He said that he attempted suicide on two occasions as a result of the harassment and this led to his first psychiatric hospitalization in service. He was then sent to Germany for temporary duty where he again was subjected to abuse. He indicated that he fell "60 feet" and injured his feet and head. He said that he was assaulted in the ammunition room at Ramstein Air Force Base and suffered a concussion. When he returned to the United States he was taunted by another airman. He then lost his self-control and physically assaulted the airman. He was later hospitalized again for psychiatric evaluation and subsequently discharged from service. The VA physician said that the veteran was discharged with a diagnosis of anxiety neurosis. He added that he had also diagnosed the veteran with the same diagnosis, only now known as PTSD. The statement went on to allege that the veteran was given an evaluation at the VAMC in Cincinnati, Ohio, in December 1972 but was never informed of the outcome. The veteran was discouraged from filing a claim for service connection by several individuals. The Board notes that the June 1992 interim summary did not relate any credible supporting evidence of a stressor supporting a diagnosis of PTSD or relate any psychiatric diagnosis to service. However, the "addendum" by the VA physician, in a complete contrast, now related the veteran's PTSD to the stressor of harassment in service due to the veteran's "Jewish status." Associated with the claims file are VA treatment records for the period from October 1991 to June 1992. The records contain many daily entries related to the veteran's inpatient status and subsequent stay at the VA domiciliary. Of particular note is an October 5, 1991, history which indicated the veteran was feeling a number of different stressors, none of which were related to the military, and that he was having flashbacks regarding the traumatic loss of his fingers. An October 8, 1991, entry reported that the results of a Minnesota Multiphasic Personality Inventory-2 (MMPI-2) psychological test were not predictive of any particular Axis I or Axis II diagnosis. There were no military stressors listed. The veteran testified at a hearing at the RO in March 1993. The veteran submitted several documents in evidence at the hearing. The first was an "example" of an Air Force form that he theorized should have been prepared for his discharge from service. This form does not list the appellant as being the subject airman of the document. The second was a listing of criteria to establish a diagnosis of PTSD as found in the Third Edition, revised, of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). The last item was a PTSD questionnaire completed by him which he felt indicated that he had PTSD. He also referred to a March 1993 letter from his VA physician which related his psychiatric diagnoses, to include PTSD, to service. The veteran related his harassment in service due to his being Jewish. He also recounted how he was thrown down stairs as part of the harassment. He said that his military records noted that he was Jewish and that others had access to his records to find this fact out. He said that his VA physician, who had diagnosed PTSD, had reviewed his SMRs when making the diagnosis. The veteran further testified as to how he lost the distal phalanges on his middle and index finger of the right hand in 1976. He also indicated that he was working at the VAMC in Dayton while at the domiciliary. The veteran submitted numerous statements, dating from April 1993, in support of his claim. Interestingly, these private lay statements were again submitted on official VA memorandum forms rather than personal stationary. He essentially restated his arguments in favor of service connection for his claims. He also submitted multiple copies of definitions from a medical dictionary of such terms as bilateral, patella, femur, and, arthritis, along with illustrations. He did not submit any competent evidence to relate any the material to his case. The veteran was afforded a series of VA psychiatric examinations in June 1993. Two examinations were by psychiatrists and the third by a psychologist. In the first psychiatric examination, the examiner stated that the veteran's claims file and hospital chart were reviewed. The veteran gave a history of being adopted. He said that he was born in the "Jewish Hospital" in Cincinnati, Ohio. The examiner reported that, throughout the examination, the veteran was not certain about any definitive situation, and that he was always doubtful and questionable in his responses. The veteran gave varying answers as to the number of abusive incidents during service. He added a new incident of where a man in a hood tried to sexually assault him. The examiner noted that the statement from the veteran's VA physician indicated two suicide attempts in service. However, the veteran did not relate any such fact to the examiner. The veteran also carried a piece of plastic which he alleged that other residents had tried to use to kill him. He also said that they had been putting plastic on his bed and pictures of Hitler on his locker. When he was confronted with his many inconsistencies he became almost teary eyed. The examiner stated that there was no Axis I diagnosis. He diagnosed a personality disorder with previous substance abuse, alcohol on Axis II. The examiner also said that he could find no basis for a diagnosis of PTSD. He saw evidence of an adjustment disorder. The examiner further stated that the veteran had probably related so many lies during his life that he had lost perspective on what was real and what was not. The examiner noted that the veteran's records reflect that he had been married three times. He told the examiner that he had been married once and that his wife had died. The examiner opined that the veteran was not telling all of the truth and he did not see any evidence of PTSD. If the veteran had some depression in the past, it was related to his personality problems with his wife or girlfriend at the time. The VA psychologist reported that the veteran said that he experienced problems in service beginning in basic training. The appellant reported that he was harassed and ridiculed because of his Jewish faith, and for being too thin. He related being attacked by a peer. He alleged that the peer lied about the attack and said that he pointed a weapon. He described other incidents of abuse and assault in service, and having flashbacks relating to the incidents. The veteran said that in 1971 he took an overdose of Darvon, consisting of 100 pills, but he recovered notwithstanding the complete lack of medical treatment. In regard to his upbringing, the veteran said that although he was "Jewish" he had a Christian upbringing by his adoptive parents. He related much the same information of discovering his natural mother just prior to entering service. He married in 1980 and divorced in 1982. The examiner reported that psychological test data reflected that the veteran represented himself as being in significant turmoil. Additional findings were related from the testing. The examiner, using DSM-III-R, provided an Axis I diagnosis of dysthymia, primary type, early onset. He also provided an Axis II diagnosis of personality disorder, not otherwise specified, with dependent, anti-social, and immature features. The examiner further commented that, while the veteran may well have suffered prejudicial treatment and abuse in service as he has stated, the data, including clinical interview, psychologic testing, narrative and clinical history did not support his claim of PTSD. Additionally, while the veteran may have suffered an adjustment disorder at some point historically, secondary to his reported experiences in service, the balance of the data were not consistent with PTSD. The examiner stated that the data reflected that the veteran had had an Axis II character disturbance which was in evidence prior to his alleged military experiences. While these experiences may have exacerbated existing pathology, the examiner did not believe that the data support the alleged experiences as etiologic to his psychiatric difficulties. The examiner further stated that it was documented that the veteran admitted to being an addictive liar and that this must cast his narrative, to some degree, in a suspicious light. The second VA psychiatrist reviewed the veteran's file as well as the two previous reports. The examiner reported that it was difficult for the veteran to stay on track during the interview. He said that it was very hard to find objective evidence consistent with the subjective reports of the veteran. The veteran reported having been married once with his wife dying in a car accident. The examiner reported that the available records contradicted the veteran's story as to the number of marriages and children. He said that the veteran did not report the information of his wife's death in the manner of somebody who was confused but rather of somebody who conveyed a picture of certainty and confidence and was quite adamant about the correctness of the information provided. The veteran reported that he was heavily involved in Jewish community activities, however, he made virtually no reference to the activities during the entire two hour interview. The examiner's assessment was no Axis I diagnosis. He said that the veteran had a borderline personality disorder. He also provided a diagnosis of impulse disorder - lying. He said that this was somewhat speculative. The examiner opined that the veteran lied for several reasons including a need to inject color into his past life to give him a sense of importance with other people which would otherwise be lacking. He also said the veteran derived a sense of power if he was able to fool other people, particularly professionals. The examiner was unable to diagnose PTSD, any form of generalized anxiety disorder or other primary anxiety disorder, or confidently diagnose any primary affective disorder such as unipolar depression or bipolar affective disorder. He was very impressed by the discrepancies that were repeatedly evidenced in the course of the examination when the veteran would say one thing and then it would not be supported by what was objectively observed. Associated with the claims file are two progress note entries dated in June and July 1993. The July entry, written in long hand and "signed by" the veteran's VA physician, states that he was admitted in October 1991 with symptoms that included depression and flashbacks about his personal life. The note indicated that the flashbacks surfaced primarily when he was under the influence of alcohol or was going through some personal problems with his wife. He would become impulsive during these periods. He agreed with the diagnoses provided by the two VA psychiatrists of dysthymia disorder and impulse control disorder. The June 1993 entry was from the Social Work Service. The entry reflected that the veteran was afraid to transfer to a different ward due to threats of physical harm. He attributed the threats to his being Jewish. In February 1994 the veteran submitted another statement, ostensibly from his VA physician, which confirmed his diagnosis of PTSD, linking it to his prior diagnosis of anxiety neurosis. The statement also said that the veteran should be afforded an "unbiased" Compensation and Pension (C&P) examination. The statement was typed on a progress note and stamped from the MHC. Associated with the claims file is a discharge summary which indicates that the veteran was discharged from domiciliary status on September 9, 1994. The form reflected that the veteran had been a resident since November 1991. The pertinent final diagnoses were: personality disorder, with dependent, anti-social and immature features; and dysthymia. Also associated with the claims file is a discharge summary for a period of inpatient psychiatric treatment dated from September 9, 1994, to September 22, 1994. He complained of flashbacks and nightmares of physical abuse and an attempted rape when he was in service. The veteran related that he told a lot of lies out of fear. He related that he had been married three times with "each marriage ending in divorce." The discharge diagnoses were PTSD by history, major depression by history, and rule out dysthymia. Associated with the claims file are VA treatment records from the VAMC in Mountain Home, Tennessee, for the period from March 1995 to September 1995. The records reflect that the veteran was admitted as a homeless veteran. A psychology note, dated in March 1995, reflected that the veteran said that he had been married one time and that his wife died in an accident in 1981. Another psychology note dated in June 1995, indicated that the veteran had again been administered the MMPI-2. The veteran gave a background of being abused in the military because he was Jewish. He said he was thrown down some stairs where he sustained a "broken" leg. He said that, several weeks later, someone placed a piece of plastic in a cold drink. He gave other examples of abuse in service. The results of the MMPI-2 were considered valid and did not support a diagnosis of PTSD. They were indicative of an anxiety disorder, not otherwise specified. The psychologist said that the veteran's symptoms appeared to be related to his past history of trauma in the military and could be affecting his present physical status or be exacerbated by his physical condition. The veteran's case was remanded in June 1996. In addition to obtaining pertinent outstanding treatment records, the RO was requested to obtain a current VA examination for the veteran's psychiatric claim. The veteran was scheduled for VA examinations in August and September 1997 but failed to report. The RO sent the appellant a letter in September 1997, advising him that if he failed to report for the scheduled examinations or failed to explain that the failure to contact the RO to reschedule the examinations could result in the claim being reviewed without benefit of recent examinations. The letter was sent to an address provided by the veteran during a personal telephone conversation with a rating specialist at the RO in March 1996. The letter was returned to the RO in September 1997 with a note from the resident that the veteran did not live at that address. The Board notes that the letter was opened and then returned, even though it was addressed to the veteran. As part of the Board's remand, the RO obtained extensive copies of VA treatment records for the veteran dating from February 1986 to June 1998. Many of the records were duplicates of evidence previously discussed. Some of the records pertained to treatment of the veteran's right knee complaints and unrelated conditions. Of note are additional records related to the veteran's period of hospitalization in October 1986. They clearly reflect that he reported belonging to the Catholic faith at the time of his inpatient stay. The veteran said that he had been in Vietnam, from "1971 to 1976," was having a terrible time dealing with his feelings of "survival guilt," and that he had lost four close friends there. He said that his first wife was killed in a car accident in 1977 and that he had been married for the second time for five years. He related his flashbacks and nightmares to the loss of his fingers. He made no mention at all of any type of trauma suffered in service. Nor did he indicate at any time that he was Jewish. He also said that he was adopted and had "no idea" who his biological parents were. Also included were additional records related to his inpatient period from September to October 1990. In a progress note entry dated September 27, 1990, he admitted that he had a problem with lying and not being honest with himself and his family. There was no mention of any type of harassment in service or reference to his being Jewish. A July 18, 1991, MHC entry noted that the veteran was referred for "relaxation training." He was suffering from flashbacks, not related to the military, and was having marital problems. He was a "recovering liar" and tended to become depressed and anxious. Additional records for the veteran's period of hospitalization and domiciliary stay from October 1991 to September 1994 reflected a number of different psychiatric diagnoses. Several of the diagnoses were related to service by the respective treatment providers to include staff psychiatrists, psychologists and social workers. However, all of the nexus opinions were based upon the veteran's unverified statements of harassment in service. None of the opinions indicate that the veteran's SMRs were reviewed and an assessment made of his two inpatient evaluations relating to problems with his girlfriends. Any diagnosis made was based totally on a history provided by the veteran. Also included in the records were essentially daily entries related to his period of hospitalization from October 5, 1991, until his discharge and transfer to the domiciliary on November 7, 1991. An assessment dated October 6, 1991, noted that the veteran was emotional from going through a divorce and having flashbacks related to the accident involving the loss of his fingers. There was no mention of any inservice harassment at that time. The October 28, 1991, diagnosis of PTSD, was not based on credible supporting evidence of an inservice stressor. Records related to the veteran's domiciliary stay contain the first reference to harassment while in the military. The veteran was screened for admission to a PTSD group on November 6, 1992. On this occasion he related that he had nightmares, flashbacks, and intrusive thoughts related to physical abuse from his wife. He told the screener that these feelings aroused additional nightmares and flashbacks from harassment in service. He alluded to a possible sexual assault as well. The veteran was noted to be placed on a Kosher diet, per his request, based on entries dated in October 1993. In an entry dated in June 1994, the veteran informed the health technician that he was recently married. Yet in an entry dated in August 1994, the veteran said that he had slipped and injured his left shoulder as a result of his girlfriend, not his wife, having waxed the kitchen floor. Associated with the claims file are treatment records from the Mountain Home domiciliary from January 1998 to June 1998. The records reflect that the veteran was homeless. He was admitted to the domiciliary so that he could work and get himself established. The only reference to the veteran's psychiatric condition was that he had a claim pending with VA. Evidence of record shows that the veteran was scheduled for a VA mental disorder examination in October 1998 but failed to report. He submitted a statement in December 1998 wherein he stated that he was willing to report for a VA examination. However, the claims file indicates that the veteran again failed to report for an examination scheduled in January 1999. The Board notes that a supplemental statement of the case (SSOC), dated in February 1999, and a letter, dated in July 1999, informing the veteran that his case was being forwarded to the Board were mailed to the address provided by him in December 1998. The SSOC noted that the veteran had been scheduled for several examinations but had failed to report for them. Neither the SSOC nor the letter were returned as undeliverable or addressed to the wrong address. The veteran made no reply to the SSOC and did not provide good cause for why he failed to report for his examinations. Accordingly, the veteran's claim will be adjudicated based upon the evidence of record. 38 C.F.R. § 3.655(b) (1999). At the outset the Board finds that the veteran is not credible. He has repeatedly offered false, fictitious, fallacious and misleading statements to health care providers, VA personnel, and even under oath to VA hearing officers. Taken as a whole, the record clearly and unmistakably shows that the veteran's recollections and statements cannot be trusted and he has zero credibility with this Board. The evidence that he has presented must be viewed in this light. In this regard, the appellant's first psychiatric treatment in May 1971 was the result of his own expression of not being able to stop telling "untruths." He lied to his first sergeant about his father having a heart attack so that he could obtain leave. After service, he has told differing accounts about the number of marriages he has had and how they have ended. In 1986, he claimed he was a Vietnam War veteran, and that he experienced survival guilt and had difficulty coping with his "Vietnam experiences." He has also stated that he was Jewish in service when his records clearly note that he indicated that he was of the Catholic faith. Similar expressions of faith in Catholicism were recorded by VA in 1986. Even assuming that the veteran was Jewish while on active duty, the record still shows that any stress he experienced in service was a result of failed personal relationships not because of any religious harassment. The first documentary evidence regarding the veteran being a practicing Jew is the October 1993 dietary note to provide a Kosher diet. There is, however, no credible evidence to support the allegation that he was the victim of religious harassment, physical assault, or even more outlandish, a victim of a sexual assault. The June 1993 examinations by the two psychiatrists and one psychologist uniformly revealed no evidence to support a diagnosis of PTSD. Rather, the psychiatrists attributed the appellant's psychiatric condition to personality disorders, as did the psychologist who also provided a diagnosis of dysthymia that was unrelated to service. Indeed, the psychologist stated that even if the veteran experienced the claimed harassment in service, he still did not have PTSD. The veteran underwent psychological testing in October 1991, June 1993, and June 1995 with all of the tests indicating no support for a diagnosis of PTSD. Finally, the September 1994 discharge summary from the veteran's domiciliary stay gave a primary diagnosis of personality disorder, not PTSD. The September 1994 VAMC discharge summary only noted PTSD "by history." The only clinical diagnoses of PTSD of record come from treating physicians that either based their findings on the history of harassment in service provided by the veteran or on his nonservice-related stressors. There is no indication that any of these health care providers reviewed the veteran's SMRs to ascertain whether there was credible supporting evidence of the alleged stressor. There is not one clinical entry which reflects a discussion of the stressors claimed, a review of the SMRs, and the veteran's current condition. The Board notes that the veteran's claimed stressors of harassment and abuse in service have not been verified and they are not a basis to support a diagnosis of PTSD. Lay evidence alone from the veteran is not sufficient to support the occurrence of a stressor. Moreover, he has not submitted any corroborative evidence in support of his claim. The Board notes that the June 1992 interim summary did diagnose PTSD, but did not relate a verified stressor to service. Indeed, the progress notes for the veteran's treatment at that time reflect that he admitted to stressors relating to abuse from his wife and memories of the traumatic loss of his fingers. The addendum allegedly submitted by the veteran's VA physician in November 1992, contradicts the interim summary and narrates a history of abuse in service, and relates PTSD, and other psychiatric diagnoses, to service. However, there is no discussion of the many other nonmilitary stressors reflected in the everyday records affiliated with the veteran's domiciliary stay or a discussion of the medical evidence that is actually recorded in the SMRs. Additionally, the veteran's VA physician prepared a handwritten, as opposed to typed, note in July 1993 where he agreed with the assessments of the June 1993 VA examiners, to include their diagnoses, which did not include PTSD. The Board notes that the July 1993 note was then contradicted by an alleged typed statement by the VA physician, dated in February 1994, wherein he said that the veteran deserved "the privledge [sic] of an un-biased, reassigned C and P exam." He also allegedly stated that he had found no evidence that the veteran had not been completely honest, open, and candid. Even if the Board believed, which it does not, that the November 1992 and February 1994 typewritten statements were prepared by a VA physician, they are contradicted by the same physician's June 1992 interim summary and July 1993 note. Moreover, while the veteran testified at his March 1993 hearing that the VA physician had reviewed his SMRs, the Board is skeptical of this allegation in light of the appellant's total lack of credibility. There is no discussion of the veteran's two inpatient periods in service, or any discussion to relate any current diagnosis to service after a review of the veteran's SMRs. If the VA examiner was cognizant that the veteran was diagnosed with anxiety neurosis in service and that he now had PTSD, the same thing only a different diagnosis as alleged by the veteran, he would have at least commented on the Air Force's medical findings relating the veteran's diagnosis to problems with his girlfriends. He also would have had to acknowledge that there was absolutely no documentary SMR evidence to support the veteran's contentions. In regard to service connection for any other diagnosed psychiatric condition, the preponderance of the evidence is against a finding that any psychiatric diagnosis, to include an anxiety disorder, adjustment disorder, depression, or dysthymia is related to service. The veteran was given a medical discharge for anxiety neurosis in 1972. However, the first evidence of any type of psychiatric treatment after service is from 1986, and the preponderance of the credible evidence of record does not indicate that the veteran now has an anxiety disorder that is related to service.. Indeed, the veteran himself does not contend that any disorder, save PTSD, are related to service. Rather, his main contention was that he suffers from PTSD because of the above described stressors. The Board is persuaded by the findings of the three VA examiners in June 1993 and the final September 1994 discharge summary from the domiciliary, after the veteran's three years of residency, that did not find any evidence of a ratable psychiatric disability that was related to service. The Board acknowledges that a June 27, 1995, entry from the Mountain Home VAMC indicated that the veteran's psychological testing was indicative of an anxiety disorder and that the disorder could be related to his trauma in service. However, as with the previous PTSD discussion, this nexus opinion presupposes the validity and credibility of the underlying history. While the opinion serves to well ground the veteran's claim, in light of the preponderating contrary evidence, it is of insufficient weight to establish entitlement to service connection. The benefit sought on appeal is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Service Connection for Right Knee As previously noted, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. In addition, the chronicity provision discussed above also is applicable in considering the veteran's claim. However, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). Three discrete types of evidence must be present in order for a veteran's claim for benefits to be well grounded: (1) There must be competent evidence of a current disability, usually shown by medical diagnosis; (2) There must be evidence of incurrence or aggravation of a disease or injury in service. This element may be shown by lay or medical evidence; and (3) There must be competent evidence of a nexus between the inservice injury or disease and the current disability. Such a nexus must be shown by medical evidence. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). At the outset the Board notes that the RO adjudicated the veteran's right knee claim as a condition that pre-existed his entry into service and not aggravated by service. This was based upon an entry dated several months into service when the veteran said that he had had problems with his cartilage in high school. However, the Board finds that the requisite criteria has not been met to show that the disability existed at the time the veteran entered service. Therefore, the veteran is entitled to the presumption of soundness in adjudicating his claim. See Crowe v. Brown, 7 Vet. App. 238, 245; 38 C.F.R. § 3.304(b) (1999). There is no prejudice in the Board adjudicating the veteran's claim on a different basis than the RO as the following discussion will show that he has failed to submit a well grounded claim. The veteran's SMRs reflect that he fell down some stairs in April 1971, for which he was received treatment for complaints of a pulled leg muscle. Complaints of right knee pain were also reported in April 1971. He was diagnosed with a pulled hamstring and released. Several days later he returned to the clinic with complaints of right knee pain. It was at this time that the veteran related a past history of "bad" cartilage in his right knee in high school in 1969. The diagnoses in April 1971 were probably right knee strain, and rule out right knee derangement. The veteran's right leg was then casted. There are no entries to reflect when the cast was removed, however, the cast was still on at the time of his hospitalization in May 1971 Early in September 1971, he suffered a bilateral calcaneal fracture when he jumped off of some F-4 wing tanks. The condition was not diagnosed right away. However, approximately two weeks later the veteran was hospitalized. Treatment records from that time reflect that he had jumped from a height of 10 feet when he sustained his injury. There was no finding of any right knee injury and the veteran did not complain of any knee problems. He was eventually transferred back to the United States. Subsequent SMRs do not address any other right knee complaints up through the veteran's discharge in May 1972. The inpatient summary from April 1972 made no findings with respect to the right knee. The March 1972 medical board and physical examination likewise made no findings in regard to the right knee. The veteran's February 1975 enlistment physical for the Ohio Air National Guard made no mention of any type of right knee problem and the veteran did not indicate one on his Report of Medical History dated that same month. However, the veteran completed two medical history forms dated in May 1976. On one form he indicated that he had no right knee problem, on the second form he indicated that he had had a "trick" knee in service due to a fall. The Board notes that the entry is hand written on the carbon copy of the form and not on the typed original. There was no comment from the examiner. There was nothing further related about the veteran's right knee. Physical examination in May 1976 revealed normal lower extremities and a right knee disorder was not diagnosed. The treatment records associated with the veteran's period of hospitalization in October 1986 do not indicate any type of right knee problem. Physical examination was negative and there was a full range of motion. An outpatient medical certificate, dated in March 1988, noted that the veteran complained of pain in his right knee. There was slight tenderness on movement but the veteran had a full range of motion. No history of injury or reference to service was made. Records associated with the veteran's period of hospitalization from September to October 1990 were also negative for any type of right knee complaints. The veteran was treated for right knee pain on January 10, 1991. He gave a history of an injury one day earlier. An orthopedic consultation dated January 16, 1991, noted that the veteran complained of right knee pain, tenderness and swelling for the past several weeks. He denied any specific injury. The assessment was rule out possible meniscal lesion. An x-ray of the right knee, dated in January 1991, was interpreted as unremarkable. A June 1992 entry reflected a diagnosis of bilateral patellofemoral arthritis. However, there was no opinion linking the diagnosis to any incident of service. X-rays of the right knee were obtained in June 1992 and interpreted to be negative. The veteran underwent arthroscopic surgery on his left knee in May 1992. The veteran was afforded a VA orthopedic examination in July 1992. The purpose of the examination was to assess the current status of the veteran's service-connected bilateral heel disability. However, no abnormal findings were noted in regard to the veteran's right knee. The veteran testified at the March 1993 hearing that he injured his right knee in service and sustained cartilage and ligament damage when he was thrown down some stairs. He said that he continued to have problems from the service injury. He said that he now wore a brace on his right knee. The Board notes that the veteran submitted numerous duplicate copies of SMRs entries pertaining to treatment provided for his right knee. He also submitted copies of extracts from a medical dictionary providing definitions for arthritis, femur, patella, bilateral, as well illustrations of the femur and patella. He did not provide any competent medical or scientific evidence providing a link between the definitions/illustrations and his claim. The veteran was afforded a VA orthopedic examination in June 1993. He presented for the examination with a brace on each knee. He related a history of injury in service when he was thrown down the stairs. He complained of off and on pain and swelling. He claimed that he injured his left knee in service when he jumped from the fuel tanks in Germany. (The Board notes that an October 18, 1991, orthopedic consultation records an injury to the left knee in September 1991 as a result of playing football.) The examiner provided a description of his examination but failed to provide a diagnosis. None of the veteran's current symptomatology for the right knee was related to service. The veteran submitted a letter to the VA orthopedic examiner in June 1993. He indicated that his knees were still tender and swollen from the examination. While the veteran added several comments regarding the wording of the report, he did not provide any additional information to show that his current right knee complaints were related to his injury in service. The veteran was afforded a VA orthopedic examination by a different examiner in September 1993. This examination again focused on the veteran's bilateral heel disability. Of note is the veteran's claim that he fell 50 feet in 1971 as opposed to the recorded height of 10 feet in his SMRs. The complaints and findings were limited to the veteran's feet and ankles. The veteran underwent arthroscopic surgery of the right knee in October 1993. The operative report noted that the veteran said that he injured his right knee in service and had had problems with it since that time. The arthroscopic examination found no evidence of any ligament or meniscus damage and no evidence of chondromalacia. There was some evidence of synovitis. The veteran was afforded another VA orthopedic examination, by the same examiner from September 1993, in February 1994. The examination primarily involved the veteran's bilateral heel disability. However, the examiner noted that the veteran complained of problems with his knees. In regard to the veteran's ankles, the examiner opined that if the veteran's history of his foot injuries was true, there may well have been trauma to other parts of the foot. He was not certain as to whether the knee problems would also be included. A kinesitherapy entry dated in May 1994 noted that there was bilateral degenerative arthritis of the knees. However, there was no opinion that related the condition of the right knee to service. In reviewing the evidence of record, the veteran had an acute and transitory injury to his right knee in service. Initially treated as a pulled hamstring, the injury was later diagnosed as a probable sprain and casted. Subsequent SMRs do not record any further difficulties with the right knee. This is especially noteworthy in light of the veteran's September 1971 heel injuries. His medical board and final physical examination were negative for any right knee complaints. The first evidence post-service of a right knee problem is the March 1988 VA outpatient record. Subsequent VA treatment records documented complaints of right knee pain in 1991 and 1992 until the veteran had arthroscopic surgery in 1993. However, there is no medical opinion linking the veteran's post-service symptomatology to any incident of service. The only comments to that effect were recorded histories provided by the veteran to the different VA treatment providers. "Evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute 'competent' medical evidence." LeShore v. Brown, 8 Vet. App. 406, 409. In regard to continuity of symptomatology, and consideration under Savage, again the first recorded evidence of any treatment was in 1988, some 17 years after service. Of note, the VA medical records from 1986 to 1988 contained no reference to any type of complaints of right knee problems. Moreover, as indicated earlier, there was no medical opinion providing a nexus between the right knee pain and any incident of service. While the veteran is certainly capable of providing evidence of symptomatology, "the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge..." Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Causative factors of a disease amount to a medical question; only a physician's opinion would be competent evidence. Gowen v. Derwinski, 3 Vet. App. 286, 288 (1992). The veteran has not provided such medical opinions. Therefore, without competent evidence of a current disorder, and competent evidence linking the disorder to service this claim must be denied as not well grounded. A well-grounded claim requires more than a mere assertion; the claimant must submit supporting evidence. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Since the veteran has submitted no medical or other competent evidence to support his claim that his current right knee symptoms are in anyway related to his period of active duty, the Board finds that he has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claims are well grounded. 38 U.S.C.A. § 5107. Hence, the benefit sought on appeal are denied. As the foregoing explains the need for competent evidence of a current disability which is linked by competent evidence to service, the Board views its discussion above sufficient to inform the veteran of the elements necessary to complete his application for service connection for the claimed disability. Robinette v. Brown, 8 Vet. App. 69, 79 (1995). ORDER Service connection for an acquired psychiatric disorder, to include PTSD, and a right knee disability is denied. DEREK R. BROWN Member, Board of Veterans' Appeals The service medical and personnel records are clear in demonstrating that the veteran never served in Vietnam. The Board notes that neither psychiatrist diagnosed the veteran with dysthymia, only the psychologist did, and that the diagnosis was offered by a psychologist not named by the veteran. The Board takes administrative notice that the Republic of Vietnam officially surrendered to communist forces of the Peoples Democratic Republic of Vietnam on 30 April 1975, and that no US forces were in country after 29 April 1975.