Citation Nr: 0007710 Decision Date: 03/22/00 Archive Date: 03/28/00 DOCKET NO. 98-12 071 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder. 2. Entitlement to service connection for impotence resulting from service-connected prostatitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD R. L. Shaw, Counsel INTRODUCTION The veteran had active military service from November 1968 to June 1970. He subsequently served in the United States Army Reserve from approximately November 1974 to September 1975 and had additional periods of active duty for training in conjunction with that service, the dates of which are not shown in the record. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 15, 1997, rating decision by the Baltimore, Maryland, Regional Office (RO) of the Department of Veterans Affairs (VA) which denied the veteran's claims for service connection for post-traumatic stress disorder (PTSD) and for impotence secondary to service-connected prostatitis. The veteran testified at a hearing before the Board in Washington, D.C., on October 6, 1999, in connection with his appeal of those determinations. FINDINGS OF FACT 1. The veteran's military service included a period of duty in Vietnam during which he received combat wounds; his decorations included the Purple Heart Medal, the Combat Infantryman Badge, and the Bronze Star Medal with V (for valor). 2. During his service in Vietnam, the veteran engaged in combat with the enemy. 3. The veteran has reported a number of stressful events that occurred during his Vietnam service; the credibility of his accounts is accepted without corroboration. 4. A preponderance of the credible medical evidence is against a finding that the veteran's current psychiatric disorder constitutes PTSD or is related to military service. 5. The veteran has established service connection for prostatitis, currently evaluated as 40 percent disabling; for fibroma of the right elbow joint, rated 10 percent disabling, for osteoarthritis of the right knee, rated 10 percent disabling; and for tumefaction of the left deltoid area, rated noncompensable; the combined rating for service- connected disabilities is 60 percent. 6. The record includes competent evidence that the veteran's current impotence is related to service-connected prostatitis. CONCLUSIONS OF LAW 1. PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107, 7104 (West 1991 & Supp. 1998); 38 C.F.R. § 3.304(f) (1999). 2. The claim of entitlement to service connection for impotence secondary to service-connected prostatitis is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (Table). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection for Impotence due to Prostatitis Factual Background. The veteran's service medical records contain no reference to impotence. By a rating decision of December 27, 1970, the RO granted service connection for prostatitis and assigned a noncompensable rating. The veteran underwent a special VA genitourinary examination in September 1980. There were no complaints or findings of impotence. The diagnosis was chronic prostatitis. The veteran requested an increased rating for prostatitis in June 1996. In support of his application he submitted statements from a private physician, D. W. McDermott, M.D., dated in January, February, March and June 1996 which described treatment with multiple medications for recurrent prostatitis and difficulty with erections. In February 1996, Dr. McDermott stated that the veteran's "impotence problem is related to his chronic prostatitis which [he had] seen many times in men in their forties, but as noted on his labs he had with him today, his testosterone is marginally low." The veteran underwent a VA urology examination in October 1996. He complained of difficulty voiding, with frequency, nocturia, suprapubic pressure, and dysuria, straining to void, as well as impotence. On examination the prostate was enlarged, tender to palpation, boggy, and smooth with no nodules. He experienced occasional incontinence of urine for which he wore a pad in his undergarments. The diagnosis was chronic prostatitis. The veteran underwent a further VA urology examination in November 1996. He described a history of impotence occurring during the preceding seven months. He related that he had a normal libido and a desire for sexual activity but was unable to achieve an erection satisfactory for vaginal penetration and that this occurred more than 90 percent of the time. Treatment with Yocon increased his libido but did not change his sexual performance. The diagnoses were chronic prostatitis and impotence, probable organic etiology. Subsequent statements from Dr. McDermott dated in March 1997 and June 1998 have been received in support of the veteran's claim. The veteran testified at a hearing before the Board on October 6, 1999. He stated that Dr. McDermott had prescribed Viagra but that it had just made him sick and he had had to stop taking it. He argued that the impotence was the result of his service-connected prostatitis. After the hearing, the record was kept open for a period of 40 days to allow the veteran to submit additional evidence. In November 1999 he submitted an additional statement from Dr. McDermott regarding impotence and prostatitis. The statement noted that the veteran had been "unable to get an erection with his prostatitis." Analysis. VA regulations provide that service connection may be also granted for any disease that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (1999). The preliminary requirement for establishing entitlement to any VA benefit is that the applicant submit a claim which is sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 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 plausible, to satisfy the initial burden of § 5107. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Once the claimant's initial burden of submitting a well- grounded claim has been met, the VA is obligated under 38 U.S.C. § 5107(a) to assist the claimant in developing the facts pertinent to the claim. In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C. § 5107(a), the VA has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the Court issued a decision holding that the VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). The Court has held that, in general, a claim for service connection is well grounded when three elements are satisfied by competent evidence. Caluza v. Brown, 7 Vet. App. 498 (1995); see also Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) quoting Epps v. Brown, 9 Vet. App. 341, 343-344 (1996). First, there must be competent medical evidence of a current disability (a medical diagnosis). Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) Second, there must be evidence of an incurrence or aggravation of a disease or injury incurred in service (lay or medical evidence). Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991); Layno v. Brown, 6 Vet. App. 465 (1994). Third, there must be a nexus between the in-service injury or disease and the current disability (medical evidence or the legal presumption that certain disabilities manifest within certain periods are related to service). Grottveit v. Brown, 5 Vet. App. 91; Lathan v. Brown, 7 Vet. App. 359 (1995). For the purpose of determining whether a claim is well grounded, the credibility of the evidence is presumed. See Robinette v. Brown, 8 Vet. App. 69, 75 (1995). Where the claim involves a question of medical diagnosis or medical causation, lay assertions of medical causation or diagnosis cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Grottveit, 5 Vet. App 91 (1991); see also, Tirpak v. Derwinski, 2 Vet. App 609 (1992) (To be well-grounded, a claim must be supported by evidence that suggests more than a purely speculative basis for an award of benefits; medical evidence is required, not just allegations). In the present case, the veteran does not contend that his current impotence, which became manifest in about 1996, was present during his period of active military service but instead maintains that its onset is related to the chronic recurrent prostatitis for which he has established entitlement to service connection and which is shown to be substantially disabling. The determination as to whether the impotence was caused by prostatitis is medical in nature and cannot be based on independent medical judgment by the Board. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The medical evidence of record pertaining to impotence consists of VA examination reports and statements received from Dr. McDermott, the veteran's treating physician, but the February 1996 statement from Dr. McDermott is the only document specifically addressing the question of causation. The stated conclusion therein that the disorder is at least in part caused by prostatitis constitutes competent medical evidence of a relationship between the current disability and the service-connected prostatitis. The opinion is sufficient to satisfy the evidentiary requirements established by the various decisions of the Court. Epps, Caluza, Id. The veteran's claim for service connection for impotence secondary to service-connected prostatitis is therefore well grounded. The finding of a well-grounded claim is not the equivalent of an ultimate finding of entitlement to service connection. A review of the merits of the claim will be undertaken following completion of the evidentiary development discussed in the remand portion of this decision below. II. Service Connection for PTSD Factual Background. The veteran's service medical records, including records relating to his Reserve service, contain no reference to complaints or findings of psychiatric abnormality. The veteran underwent a VA neuropsychiatric examination in September 1990 in connection with a claim for service connection for headaches. He stated that he felt a good deal of tension and had nightmares about things he saw in Vietnam. On examination he smiled frequently but there was a good deal of tension underneath. The examiner felt that the veteran obviously felt on edge but managed this by keeping his interpersonal relationships as uncomplicated as possible. The diagnosis was anxiety, fairly mild. The veteran filed his original claim for service connection for PTSD related to combat experiences in Vietnam in April 1997. Received in support of the claim were VA outpatient progress notes dated from January to March 1997. In the earliest entry, dated January 24, 1997, it was reported that the veteran had been referred because of complaints of nightmares, insomnia, fear of going out at night, irritability and intermittent explosiveness. He reported an incident where he had hit the ground after a car backfiring thinking it was a firearm and that he was under attack. His affect was appropriate and his mood varied from being subdued to being animated to being teary eyed. He reported several incidents in Vietnam that still haunted him including: (1) Shooting a girl in the middle of the night because she was suspected of being a Vietcong, (2) assaulting a fellow soldier and breaking his jaw for falling asleep while they were setting up an ambush, (3) seeing a Vietcong pushed out of a helicopter because he refused to talk to an interrogator, (4) being a participant in torture, and (5) killing a suspected Vietcong when he could have taken him prisoner. The diagnosis was post-traumatic stress disorder. The examiner referred the veteran to a VA stress recovery program, where he was seen three days later. The veteran stated that he did not go anywhere, that he had periods of depression with suicidal thought, and that his symptoms included waking up drenched in sweat, and insomnia. The diagnosis was rule out PTSD/depression. Medication was prescribed. The veteran was seen again in March 1997. He was sleeping okay with the medication. There was no other significant change. He was still dysphoric (angry/depressed). The diagnosis was PTSD. The veteran underwent a VA psychiatric examination in January 1997. He was currently working driving a mail truck. He stated that he did not trust people and did not go places with his wife because people were out to get him. He was convinced that no one liked him and was afraid of people. He stated that he occasionally woke up sweating. He did not describe clear-cut nightmares associated with his war experiences. The examiner reported that the veteran did not suffer from flashbacks and was not hypervigilant. He indicated that he spent nearly 35 minutes with the veteran and at the end of the session the veteran told him he had asked only five questions. The veteran seemed suspicious about the interview. The examiner believed that the veteran was in no way preoccupied with thoughts of his war experiences and was difficult to interview because he kept repeating questions and saying he did not understand the question. The examiner did not believe the veteran was psychotic or that he had ever been psychotic but that there was a paranoid tinge to his thinking. The diagnosis was paranoid personality. The veteran was admitted to a VA hospital in June 1997. He described nightmares regarding events in Vietnam involving close calls, shooting people, seeing friends die, being pinned down and torturing people. On mental status the veteran was coherent and spontaneous and showed a full range of affect with a mood of hostile depression. It was reported that his Vietnam-related stressors were persistently reexperienced through distressing recollections and recurrent distressing dreams several times a week and that he experienced moderate psychological stressors and exposures, reminders or trauma-related stressors as well as moderately sociological reactivity to such reminders. The veteran was discharged with Axis I diagnosis of post-traumatic stress disorder and recurrent major depressive episodes. The discharge summary contained the following passage: He experiences moderate psychological distress at exposures, reminders or trauma-related stressors as well as moderately sociological reactivity to such reminders once or twice a week. He reports no dissociative flashback episodes within the last month, but had mild to moderate dissociative tendencies secondary to PTSD. [The veteran] experiences almost daily avoidance of stimuli associated with the trauma as evidenced by moderate efforts to avoid thoughts and feelings as well as stimuli that arouse recollections of the trauma. However, he reports only mild amnesia for his inservice stressors. He shows significant emotional numbing and more social avoidance and estrangement from all people. He reports vague complaints of a sense of foreshortened future without specifying longevity. He also endorses the following hyperarousal symptoms: Severe sleep disturbance, frequent reports of irritability and outbursts of anger, frequent difficulty with concentration infrequent (sic), but moderate to severe, startle reaction to loud, unexpected noises. The veteran underwent a VA psychiatric examination in February 1998 by a panel to two VA psychiatrists. He described combat encounters which involved atrocities toward Vietcong or Vietnamese civilians and seeing dead American soldiers who were apparently mutilated. He related that he would have liked to have continued longer in the Reserves but had been forced out because he had put in the maximum number of years allowed. He had no misgivings about being called back to active duty to participate in the Persian Gulf War. He described feelings of feeling lonely and having difficulty connecting with other people. He reported a short temper, sleeping problems, and nightmares regarding aggressive acts in Vietnam. He brought a number of photographs of Vietnam to the examination. He was rather suspicious throughout the interview and attempted to distance himself by suggesting that the interviewers could not possibly understand him since neither had been to Vietnam. His mood was lonely and his affect was neutral and normal in range. On gross examination he appeared cognitively intact. The diagnosis on Axis I was anxiety disorder, not otherwise specified, and dysthymia. The diagnosis on Axis II was paranoid personality traits. The report included the following comments: [The] veteran has some symptoms which suggest an anxiety disorder, and could be treated in the paradigm of a post- traumatic stress disorder, however, he does not meet criteria for DSM IV post- traumatic stress disorder. Particular note he does not have Part II of Criterion A for this disorder. No doubt his experiences in Vietnam are quite horrific, but at that time, his responses to these situations involved him maintaining adequate control over the situation and in fact, the [incidents] that are most disturbing to him, he, in fact did have some measure of control over the nature and degree of the trauma. Further, this veteran's current level of function, while somewhat impaired in the social realm, does reflect a rather good level of functioning....thus, most likely this patient has a mixture of both an affective and mostly depressive disorder and an anxiety disorder, but not PTSD and his level of function is still good. At the October 1990 hearing before the Board, the veteran and his representative disputed the validity of the findings reported at the February 1998 examination, arguing that it showed no psychometric diagnostic testing such as the MMPI or the Combat Inventory Profile or the Beck Inventory. He criticized the report as being only a single report rather than two separate reports, one by each examiner. The veteran provided additional testimony concerning his current symptoms and his experiences in service. He requested that another psychiatric examination to include psychological testing be performed if the appeal could not be allowed on the present record. At the hearing the veteran submitted photocopies of a number of photographs taken in Vietnam which appear to show dead bodies. Analysis. In general, under the applicable VA law and regulations, service connection may be granted if the weight of the evidence establishes that a disability was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110 (wartime), 1131 (peacetime) (West 1991 & Supp. 1998). 38 C.F.R. § 3.303(a) (1999). VA regulations also provide that, notwithstanding the lack of a diagnosis in service, service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertaining to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 1991 & Supp. 1998); 38 C.F.R. § 3.303(d) (1999); see Cosman v. Principi, 3 Vet. App. 503, 505 (1992). The veteran has clearly satisfied his initial burden of submitting a well grounded PTSD claim. The record on appeal includes outpatient treatment records and a January 1997 hospitalization report containing a diagnosis of PTSD. The medical evidence of a current PTSD diagnosis is sufficient both to identify the current disability and describe a generalized connection between the disability and service. Cohen v. Brown, 10 Vet. App. 128 (1997); Caluza, Id.; Grottveit v. Brown, 5 Vet. App. 91 (1991). The record also contains presumed-to-be-credible lay evidence regarding the circumstances of service and the occurrence of a PTSD stressor. Where the determinative issue does not require expertise, lay testimony may suffice by itself to satisfy the well-groundedness requirement. See Caluza, Grottveit, Id; Heuer v. Brown 7 Vet. App. 379, 385 (1995); Cohen, Id. The VA is obligated by statute to provide assistance in the development of facts pertinent to a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103, 3.159 (1999). The duty to assist requires that medical records and medical examinations be obtained where indicated by the facts and circumstances of the individual case. Littke v. Derwinski, 1 Vet. App. 90 (1990). In this case, all available service department and VA medical records have been obtained. Since the veteran has not indicated that he has been treated for his psychiatric symptoms by a private physician or specified any additional documents which would support his claim, no attempts to obtain additional information from private sources is warranted. Olson v. Principi, 3 Vet. App. 480 (1992). The veteran has been examined twice by the VA in connection with his PTSD claim, including an examination by a panel of two psychiatrists performed for the express purpose of reconciling the conflicting evidence as to the current psychiatric diagnosis. These actions are sufficient to satisfy the Board's statutory obligations. For the reasons discussed below, the veteran's various criticisms of the February 1998 panel examination are not compelling and do not warrant the scheduling of a reexamination. The Board finds that no additional effort on the part of the VA to assist the veteran in the development of his PTSD claim is indicated or warranted. A VA regulation, 38 C.F.R. § 3.304 (1999), sets forth the substantive elements required to establish service connection for PTSD. The version of the regulation in effect before March 7, 1997, provided that service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. If the claimed stressor was 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 was accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed stressor. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(f). Effective March 7, 1997, the regulation was amended to read as follows: Service connection for PTSD requires medical evidence diagnosing the condition in accordance with Sec. 4.125(a) of this chapter, a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed inservice stressor actually occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is consistent with the circumstances, conditions, and hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of Sec. 3.1(y) of this part and the claimed stressor is related to that prisoner-of-war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions and hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (effective May 7, 1997). Authority: 38 U.S.C.A. § 1154(b) (West 1991); When a change occurs in an applicable statute or regulation after a claim has been filed but before a final decision has been rendered, the Board must apply the version which is most favorable to the claimant, unless Congress has expressly provided otherwise or has authorized VA to provide otherwise and VA has done so. Karnas v. Derwinski, 1 Vet. App. 308(1991). As the Board finds herein that the veteran does not have PTSD, neither the new nor the old version of 38 C.F.R. § 3.304(f) is favorable to his claim. The evidence necessary to establish the occurrence of a stressor for PTSD varies, depending on whether or not the veteran "was engaged in combat with the enemy." Zarycki v. Brown, 6 Vet. App. 91 (1993). Adjudication of a PTSD claim therefore requires evaluation of the evidence in light of the place, type, and circumstances of service. If the veteran's service involved actual combat with the enemy, he is entitled by virtue of 38 U.S.C.A. § 1154(b) (West 1991) to have his claim reviewed under a relaxed evidentiary standard; where it is determined that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, the veteran's lay testimony regarding claimed stressors must be accepted as conclusive as to their occurrence, and no further development or corroborative evidence will be required, provided that the veteran's testimony is "satisfactory" and "consistent with the circumstances, condition, or hardships of such service." Zarycki, Id., Caluza , Id. For combat veterans alleging a combat-related disability, 38 U.S.C.A. § 1154(b) allows the use of lay evidence to establish service incurrence of a disability both in establishing the well groundedness of the claim and in the determination as to the merits of such claim. 38 U.S.C.A. § 1154(b) (West 1991 & Supp. 1998); 38 C.F.R. § 3.304(d) (1999); see also Collette v. Brown, 82 F.2d 389, 392-93 (Fed. Cir. 1996); Libertine v. Brown, 9 Vet. App. 521 (1996); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The applicability of this provision to PTSD claims is in fact the foundation of the PTSD regulation, 38 C.F.R. § 3.304(f), and has been incorporated into the analysis of numerous decisions of the Court. See Cohen v. Brown, 10 Vet. App. 128 (1997); Zarycki v. Brown, 6 Vet. App. 91 (1993), West (Carelton) v. Brown, 7 Vet. App. 70 (1994). The veteran has reported a number of events which he claims to have witnessed in service and which constitute the claimed stressors for PTSD. The stressor events are not of a type that would be likely to be documented in the official record. However, the veteran is clearly a combat veteran for PTSD purposes by virtue of the fact that he received the Combat Infantryman Badge for combat operations as well as the Purple Heart Medal for wounds received in combat, and because of that status he is entitled to the benefit of the relaxed evidentiary standards allowed by 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d). His allegations regarding inservice stressors for PTSD must be accepted as credible despite the lack of corroborating documentation. By contrast, the regulatory requirements that there be a current diagnosis of PTSD and a nexus between current disability and inservice trauma may be satisfied only through medical evidence, regardless of which version of the regulation is applied. Cohen, Id. In the present case, the diagnostic evidence is conflicting as to the identity of the veteran's current psychiatric pathology. At the earliest psychiatric evaluation shown in the record, performed in September 1970 at the time of the veteran's original application for benefits, mild anxiety was reported. After receipt of the veteran's claim for service connection for PTSD in November 1996, a VA psychiatric examination was performed, in January 1997, which resulted in a diagnosis of paranoid personality. Later that same month, the veteran sought outpatient treatment for PTSD and was referred to a PTSD program where PTSD was diagnosed on two occasions, in January and again in March 1997. The hospitalization of the veteran in June 1997 led to a diagnosis of PTSD. In the face of these conflicting diagnostic judgments, the RO sought to reconcile the discrepancy by obtaining a further examination by a panel of psychiatrists. Both of the examiners concluded that a PTSD diagnosis was not established, and the Board must now determine which of the diagnoses of record should control the outcome of the claim. To comply with the statutory requirements of 38 U.S.C. § 7104(d) to provide "reasons or bases" for its decisions, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide reasons for its rejection of any material evidence favorable to the veteran. Eddy v. Brown, 9 Vet. App. 52 (1996); Meyer v. Brown, 9 Vet. App. 425 (1996); Gabrielson v. Brown, 7 Vet. App. 36 (1994); Gilbert v. Derwinski, 1 Vet. App 49 (1990). The Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the Court has stated, in pertinent part: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . .As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The determination as to credibility is in the province of the Board. It is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The record provides no basis for differentiating among the level of skill or expertise of the physicians who have expressed opinions as to the presence or absence of PTSD; all must be assumed to be competent medical professionals. The opinions favorable to a finding of PTSD consists primarily of a January 24, 1997, outpatient treatment entry and the report of the June 1997 hospitalization, both of which itemize a number of symptoms attributed to PTSD. The outpatient treatment reports note a number of psychiatric symptoms but do not specifically enumerate enough of the specific manifestations required by version III-R or IV of the Diagnostic and Statistical Manual of Mental Disorders (DSM- III-R) (DSM-IV) of the American Psychiatric Association to support a diagnosis of PTSD. The hospitalization report, particularly the portion quoted above, consists largely of a list of pathological findings described exclusively in the language of the diagnostic criteria. Essentially no raw data or analysis of the significance of the findings is set forth. The report of the panel of psychiatrists may be distinguished because, unlike any of the medical documents containing a diagnosis of PTSD, it was based on a review that included a study of the veteran's entire file and was less dependent on information received from the veteran directly. More importantly, the report contained a critical evaluation of the findings observed on examination as they relate to the criteria for a PTSD diagnosis. The examiners conceded the existence of some PTSD symptoms but noted the absence of others which are required to support the diagnosis, noting in particular the lack of findings under Part II of Criterion A for a PTSD diagnosis (requiring that the individual's response to the traumatic event have "involved intense fear, helplessness, or horror"). This conclusion is credible and consistent with the record, and the Board does not have the discretion to disregard it. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The VA panel evaluation sets forth extensive detail and provides a "thorough and contemporaneous medical examination." See Stanton v. Brown, 5 Vet. App. 563 (1993). The panel provided an unequivocal statement that supports the conclusion that the veteran does not have PTSD. The conclusion so stated is the more persuasive of the diagnostic judgments contained in the record and the Board adopts it as the basis for deciding the present appeal. The veteran has attacked the panel examination on the basis that it did not incorporate certain psychological tests which he claims are necessary for a diagnosis of PTSD. However, the VA examiners are presumed to be competent to determine which tests and studies are necessary to ensure that a diagnosis is properly established, to interpret the results of the studies, and to make a determination as to whether further inquiries are required. The Court in Cohen, Id., gave medical diagnosticians ample leeway to make whatever judgments are necessary to establish the diagnosis. As noted above, the examination report is complete and detailed and reflects both observation of the veteran and a study of the record. In the absence of any indication to the contrary, the fact that the examiners filed a single report rather than individual reports does not suggest that their opinions were not in agreement with one another or that the report should be given a lesser degree of credibility and probative weight. With respect to the veteran's own opinion that he has PTSD, the Court has been clear in stating that a veteran is not competent to provide a medical opinion diagnosing himself with PTSD. See Hyder v. Derwinski, 1 Vet. App. 221, 225 (1991); Contreras v. Brown, 5 Vet. App. 492 (1993). In reaching its decision, the Board does not dispute that the veteran experienced traumatic events in service. Though the occurrence of stressful events must be conceded, a preponderance of the credible evidence of record militates against the veteran's claim with respect to the critical findings as to the existence of current PTSD related to those events, and the existence of a nexus between any current psychiatric symptomatology and military service, in accordance with the regulatory requirements. Since a preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b). ORDER The claim of entitlement to service connection for impotence secondary to prostatitis is well grounded. To that extent only, the appeal is allowed. Service connection for PTSD is denied. REMAND The law requires full compliance with all orders in this remand. Stegall v. West, 11 Vet.App. 268 (1998). Although the instructions below should be carried out in a logical chronological sequence, no instruction in this remand may be given a lower order of priority in terms of the necessity of its being carried out completely. Because the claim of entitlement to service connection for impotence secondary to prostatitis is well grounded, the VA has a duty to assist the appellant in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159 (1999); Murphy v. Derwinski, 1 Vet. App. 78 (1990). The actions required to satisfy the duty to assist include procurement of relevant medical, Littke v. Derwinski, 1 Vet. App. 90 (1990), and a thorough and contemporaneous examination that takes into account the records of prior medical treatment and prior examinations. Green v. Derwinski, 1 Vet.App. 121 (1991); Lineberger v. Brown, 5 Vet. App. 367 (1993); Waddell v. Brown, 5 Vet. App. 454 (1993); 38 C.F.R. § 3.326. Adjudication of the issue of entitlement to service connection for impotence secondary to prostatitis entails a determination as to whether there is a medical relationship between the service-connected prostatitis and the development of impotence. The finding that the records from Dr. McDermott suggest such a cause-and-effect relationship is sufficient to well ground the claim, but an additional medical opinion on this question is required in order to support a claim of service connection by a preponderance of the evidence. A special VA examination by a specialist in genitourinary diseases should be performed. The examination should be preceded by requests for any additional examination or treatment records that may be available. In addition, the suggestion by Dr. McDermott that the prostatitis may be only a partial cause of impotence raises a question as to whether the veteran may be entitled to service connection for aggravation of impotence by the prostatitis pursuant to Allen v. Brown, 7 Vet. App. 439 (1995), in the event that proximate causation under 38 C.F.R. § 3.310(a) (1999) is not demonstrated. This question is inextricably intertwined with the issue of proximate causation. Harris v. Derwinski, 1 Vet. App. 180 (1991); Kellar v. Brown, 6 Vet. App. 157 (1994), Parker v. Brown, 7 Vet. App. 116 (1994). The matter must be addressed as part of the present appeal. In Allen, the Court held that the term "disability" for service connection purposes "refers to impairment of earning capacity, and that such definition mandates that any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, shall be compensated." Allen, at 448 (emphasis in original). Thus, when aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing before the aggravation. In other words, a veteran is entitled to service connection for any increment in the severity of a nonservice-connected disability attributable to a service-connected disability. In determining entitlement under the Allen analysis, a VA examination to identify and define any increment of additional impotence caused by the service-connected prostatitis must be performed. Where the record before the Board is inadequate, a remand is required. Green v. Derwinski, 1 Vet. App. 121 (1991). Accordingly, the case is remanded for the following actions: 1. The RO and any physician to whom this case is assigned for an examination and/or a statement of medical opinion must read the entire remand, to include the explanatory paragraphs above the numbered instructions. 2. The RO should take appropriate steps to obtain any additional VA outpatient treatment records dated since March 1997, the date of the most recent records currently on file. 3. The veteran should be given an opportunity to identify all medical providers, both VA and private, including both physicians and institutions (hospitals or clinics), from which he has received examination or treatment for impotence at any time since service. Upon receipt of proper authorization, the RO should attempt to obtain all available documentation from the physicians or other providers identified by the veteran. 4. The RO should take appropriate steps to schedule the veteran for a special VA examination by a urologist to determine the nature and etiology of the current impotence and ascertain its relationship to service-connected prostatitis, if any. All indicated tests and studies should be performed, and all clinical findings should be reported in detail. It is essential that the claims folder be provided to the examiner for review in conjunction with the examination, together with a copy of this remand. On the basis of current examination findings, review of the file, and any additional information obtained from the veteran, the examiner should respond to the following questions and provide a full statement of the basis for any conclusions reached. (a) Is it more likely than not, as likely as not or less likely than not that the current impotence is due to or the proximate result of the service-connected prostatitis? (b) If, and only if, the answer to the foregoing question is that it is less likely than not that impotence is proximately due to prostatitis, the following question should answered: Is it more likely than not, as likely as not or less likely than not that the service- connected prostatitis has caused chronic aggravation of the impotence? If so, the amount of the aggravation should be described and quantified. 5. After completion of the foregoing, the RO should review the examination report received to ensure that it is adequate to achieve the purposes of this remand. If the requested information has not been provided, the report should be returned as inadequate for rating purposes pursuant to 38 C.F.R. § 4.2 (1999). If this is necessary, the physician who performed the examination should be given an opportunity to amend the report without reexamining the veteran but should be free to schedule a reexamination if necessary. All other necessary follow-up actions should be taken. 6. When the record is complete, the RO should review the issue of entitlement to service connection for impotence secondary to prostatitis. If the determination is adverse to the veteran, a supplemental statement of the case should be prepared and the veteran and his representative should be given a reasonable period of time for reply. Thereafter, the claim should be returned to the Board for further review on appeal, if in order. No action is required of the veteran until he receives further notice. The purpose of this remand is to obtain additional information. The Board does not intimate any factual or legal conclusions as to the outcome ultimately warranted in this appeal. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. G. H. SHUFELT Member, Board of Veterans' Appeals Error! Not a valid link.