Citation Nr: 1121952 Decision Date: 06/07/11 Archive Date: 06/20/11 DOCKET NO. 09-44 430 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a personality disorder. 3. Entitlement to service connection for psychiatric disability, other than PTSD. REPRESENTATION Appellant represented by: Minnesota Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and his mother ATTORNEY FOR THE BOARD B. Ogilvie, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1999 to July 2005, however, only the period from June 24, 1999 to August 30, 2004 is considered honorable for VA purposes. This appeal to the Board of Veterans' Appeals (Board) arose from a November 2008 rating decision in which the RO denied the Veteran's claim for an acquired psychiatric disorder, to include depression and PTSD. In December 2008, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in March 2009, and in November 2009, the Veteran filed a form that was construed as a substantive appeal. In April 2011, the Veteran and his mother testified during a Board hearing before the undersigned Veterans Law Judge (VLJ) at the RO; a transcript of that hearing is of record. During the hearing, the Veteran's representative submitted additional evidence directly to the Board, with a waiver of initial RO consideration of the evidence. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2010). The Board notes that, while the RO originally characterized the psychiatric claim on appeal as one for service connection for an acquired psychiatric disorder, to include anxiety, PTSD, and depression-consistent with the Veteran's actual psychiatric diagnoses, Clemons v. Shinseki, 23 Vet. App. 1 (2009), and other legal authority-the Board has recharacterized this appeal as encompassing the three issues reflected on the title page. The Board's decision addressing the matters of service connection for PTSD and for a personality disorder is set forth below. The claim for service connection for a psychiatric disability, other than PTSD, is addressed in the remand following the order; that matter is being remanded to the RO, via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the appellant when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each matter herein decided have been accomplished. 2. While the objective evidence does not indicate that the Veteran engaged in combat with the enemy during service, there is credible evidence of record that corroborates that his unit was exposed to improvised explosive device (IED) attacks. 3. Although the record reflects a diagnosis of PTSD, the weight of the competent, persuasive medical evidence indicates that the Veteran does not meet the diagnostic criteria for service-related PTSD. 4. The Veteran's diagnosed personality disorder is not a disability for VA compensation purposes. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2010). 2. The matter of service connection for personality disorder is without legal merit. 38 U.S.C.A. § 1110, (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 4.9, 4.127 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2010)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2010). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in an October 2008 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for service connection for an acquired psychiatric disorder, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. This letter also included information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. The November 2008 rating decision reflects the initial adjudication of the claim after issuance of this letter. Hence, the October 2008 letter-which meets the content of notice requirements described in Dingess/Hartman and Pelegrini-also meets the VCAA's timing of notice requirement. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of service treatment records, private treatment records, Social Security Administration records, and the report of an December 2009 VA examination. Also of record and considered in connection with this matter are various written documents provided by the Veteran, and by his mother and his representative, on his behalf. The Board also finds that no additional RO action to further develop the record in connection with these matters is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. Through notice of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate this claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with either matter. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Background Service treatment records reflect that, on entrance examination in March 1999, the Veteran's psychiatric findings were marked as normal. The Veteran denied any history of psychiatric symptoms and ever attempting suicide. Personnel and service treatment records also reflect that the Veteran deployed to Iraq in support of Operation Iraqi Freedom in February 2004 for one year. On his post-deployment health assessment questionnaire taken in February 2005, the Veteran marked that he did not see anyone wounded, killed, or dead during the deployment, did not ever feel that he was in great danger of being killed during the deployment, and negatively responded as to whether he was feeling any symptoms of depression or PTSD. The Veteran reported that he engaged in direct combat where he discharged his weapon. The Veteran's service treatment records are silent for any reports of psychiatric symptoms or treatment. The record contains two private treatment reports dated in January 2008 and March 2008, by a nurse and psychologist, respectively, as well as several treatment notes. On January 2008 private examination, the Veteran reported nightmares of Iraq. The Veteran's appearance and grooming were casual. Behavior was restless. The Veteran's mood was irritable and labile, and his affect was somewhat constricted. Speech was clear. The Veteran described horrific nightmares, PTSD, and flashbacks. Thought process was tangential and circumstantial. The Veteran seemed to be somewhat delusional and paranoid. Insight and judgment were fair, and cognition and memory appeared intact. The Veteran was diagnosed with prolonged PTSD and a mood disorder. In March 2008, the Veteran met with a private psychologist. On mental status examination, the Veteran was alert and oriented. He was easily engaged and appeared in no significant distress. The Veteran was adequately groomed, had direct eye contact, spontaneous speech, and neutral mood. Thought process was linear without evidence of psychosis. Judgment and insight were inferred to being somewhat below average. The Veteran was diagnosed with anxiety disorder NOS versus PTSD, probably delayed onset, rule out depression NOS, and sexual disorder NOS-provisional. The psychologist noted that the Veteran could have personality contributions to his current situation though baseline data was not sufficiently formulated to say with confidence. On December 2009 VA examination, the Veteran reported significant behavioral problems from an early age, including setting fires on numerous occasions, breaking curfew, heavy drinking in his adolescence, and interactions with the police. The Veteran also reported having three suicide attempts while in middle school and high school. The Veteran enlisted for active duty in June 1999. The Veteran reported that his wife left him and his grandmother died on the same day, and this was the most devastating experience while in the military. The Veteran reported that he was discharged from the military based on an argument with a noncommissioned officer. Upon further examination of the Veteran's personnel records, the psychologist found this was untrue; the Veteran was actually discharged in lieu of a court martial for sexual assault of his sister. The Veteran served in Iraq from February 2004 to February 2005 (although the Board notes that only the period from February 2004 to August 30, 2004 is under consideration for VA benefits). The psychologist found the Veteran's reporting of these experiences were not entirely consistent. The Veteran reported ongoing hallucinations, night terrors, and other symptoms from being in combat. However, many times throughout the interview, and when specifically questioned about the incidents, the Veteran denied experiencing any fear at all, or any sense of terror or hopelessness. In fact, the Veteran reported that he enjoyed being in the military and being in combat, and that he did not experience any fear for himself. The Veteran reported being caught in a firefight, where he stated that he discharged his weapon and was told he had three kills, although he did not witness these kills. Later in the interview, the Veteran contradicted this and stated that he saw people fall and knew they were likely dead. The Veteran also recounted an incident where he witnessed children and a woman killed in a car, but he denied any fear or threats to himself or physical integrity. The Veteran did not have any feelings of terror or distress about this, only feelings of regret and shame. The Veteran also reported some hallucinations, but not in relation to any specific events in which he experienced intense fear, helplessness, or horror, or where he felt a threat to his physical integrity, or well-being. The psychologist found that the Veteran's flashbacks appeared to be vague, rather than related to specific combat experiences. The psychologist found that the Veteran's reported experiences and symptoms did not make sense and were often contradictory. The psychologist found that some of the symptoms were more congruent with a personality disorder with cluster B traits. The Veteran appeared to have anxiety, and the Veteran had also been diagnosed with depression NOS. The Veteran presently denied depression other than being depressed about having to leave the military. The psychologist noted that the Veteran's private treatment notes appeared to have diagnosed the Veteran's PTSD based on the Veteran's own report that he had PTSD, and did not review specific symptoms, Criterion A events, or any other criteria for PTSD. He also noted that the private treatment records contained no review of other anxiety and depression symptoms. On mental status examination, the Veteran reported memory problems, but the examiner noted that the Veteran had suffered no traumatic events, and the memory problems that he reported were not particularly congruent with any amnesic disorders. Thought processes appeared to the examiner to be generally logical and coherent. There did not appear to be any delusions, paranoia, preoccupation, or auditory visual hallucinations, although the Veteran reported a history of significant auditory and visual hallucinations. The Veteran reported hallucinations where he felt that he was back in Iraq, although the psychologist noted that the experiences the Veteran described did not appear congruent with flashbacks per se as much as his stating that he disengages with this reality. The examiner noted that some of the Veteran's visual hallucinations were more congruent with a psychotic experience than a PTSD experience, but the Veteran did not seem particularly psychotic either. The Veteran denied depression and was reporting anxiety. Affect was somewhat flat. Insight and judgment appeared to be poor. The Veteran reported difficulty sleeping, although he could not state why, other than a fear of going back to Iraq in his mind (although on several occasions, the Veteran also stated that he enjoyed the military and combat). The psychologist found that throughout the Veteran's descriptions of his hallucinations, the Veteran appeared to be using somewhat exaggerated and extreme language in describing these experiences. The Veteran denied being a worrier although he also stated that he had muscle tension in his arms and legs every morning. When asked if he had panic attacks, the Veteran described periods of losing control and going into "flashbacks" where he would have to be restrained. From what the Veteran was reporting, the psychologist found that these did not seem to be panic attacks per se. The Veteran denied any specific obsessions or compulsive behaviors. Regarding a diagnosis of PTSD, the psychologist found that the Veteran's credibility was of concern. As noted in his claims file, the Veteran had reported difference experiences at different times. For example, at his VA examination, he reported initially not seeing the people that he reportedly shot. Later in the interview, he stated that he in fact did see those people fall down but was not sure whether they were dead. The psychologist further found that the Veteran's out-of-body, dissociation, and hallucinatory experiences did not appear quite consistent with PTSD or with psychotic disorder. The Veteran's personality test results were valid; however, they also indicated some likely exaggerated or over-reporting of symptoms. When asked by the psychologist in reviewing his checklist of lifetime distressing evidence, which events were the most disturbing or distressing to the Veteran, the Veteran reported the first event that was by far the most distressing to him, and had the most impact on him, was when his ex-wife left him and his grandmother died on the same day when he was denied leave. He reported that this experience made him shut down to all human emotions, and he no longer experienced any type of fear or concern for others. The psychologist noted that although this was a traumatic event, it did not meet Criterion A fir a diagnosis of PTSD because it was not life threatening, did not involve serious injury, was not a threat to his physical integrity, and the Veteran did not experience intense fear. Similarly, the Veteran reported that his combat experiences did not result in any intense fear, helplessness, or horror. As the Veteran did not meet Criterion A for a diagnosis of PTSD, the psychologist found that further discussion of the remaining criteria was unnecessary. The Veteran's personality testing reflected that the Veteran was experiencing significant psychological distress, but the Veteran's reported symptoms were not associated with PTSD. The results of one test was found to be congruent with PTSD, although the psychologist noted that the test was a face valid scale. The Veteran was diagnosed with anxiety NOS, personality disorder NOS, cluster B traits, and assigned a GAF score of 57. The psychologist noted that he had some concerns about the credibility of the Veteran's report due to his self-reported difficulties with memory. In the interview, the Veteran also had several inconsistencies in his reporting. The psychologist did not believe that the Veteran was intentionally inconsistent, but the inconsistencies and self-reported memory problems brought into question the credibility and accuracy of his self-report. The Veteran did have a history of conduct disorder and problematic behaviors that existed prior to joining the military. The Veteran reported drinking problems, but the pattern of alcohol use that he described was found by the examiner to be unlikely in its severity. He also endorsed three suicide attempts, but the attempts seemed somewhat out of the ordinary to the psychologist. The Veteran also denied any previous treatment prior to his current treatment for anxiety, which also did not make sense to the psychologist considering the Veteran had three suicide attempts and so many behavioral problems in school. The Veteran also initially reported the wrong reason for his discharge from the military, and later, did mention that he was arrested and charged with sexual misconduct for sexually assaulting his sister. Thus, the psychologist found that the Veteran had a history of antisocial traits and suicide attempts prior to enlisting in the military, and the psychologist believed that the Veteran likely met the criteria for a personality disorder NOS with cluster B traits, and this preexisted his joining the military. The Veteran denied depression but did endorse anxiety. In reviewing PTSD symptoms, the Veteran could not identify any specific situations which caused him intense fear, distress, or threat to his integrity or well-being. As the Veteran did not appear to meet any Criterion A for PTSD, the psychologist could not review the other symptoms of PTSD because the Veteran denied a Criterion A event. The Veteran's reported dissociation and hallucinations seemed more consistent with personality disorder NOS. The psychologist noted that the Veteran did report some symptoms of anxiety. The examiner noted that the Veteran was currently being treated for anxiety at a clinic in the community (although their diagnosis was PTSD). The psychologist noted, however, that a review of the intake indicated that the private mental health specialists appeared to diagnose the Veteran with PTSD based on the Veteran's report saying that he had PTSD. The VA examiner found that, on the intake record, there was no review of the symptoms, no review of Criterion A events, or other criteria for PTSD. The psychologist reiterated that the Veteran was involved in combat, but did not endorse any fear or particular events that caused him fear or distress or to worry about his well being or physical integrity. Thus, the psychologist found that the Veteran did not appear to meet the criteria for PTSD. The Veteran also appeared to meet the criteria for personality disorder NOS, with cluster B traits and a likely history of conduct disorder. III. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A. PTSD Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). The Board notes that, on July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the occurrence of the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010), and 75 Fed. Reg. 41092 (July 15, 2010)(correcting the effective and applicability dates from July 12, 2010 to July 13, 2010). The revisions apply to, among others, claims appealed before July 13, 2010, but not yet decided by the Board. In this case, however, VA has conceded the occurrence of the Veteran's claimed in-service stressor that he witnessed IED attacks in Iraq. The RO researched the Veteran's military personnel records, as well as the Veteran's unit history from serving in Iraq, and in November 2009, filed a report finding that the Veteran's alleged stressor was corroborated. See Souzzi v. Brown, 10 Vet. App. 307 (1997); Pentecost v. Principi, 16 Vet. App. 124 (2002). Therefore, as the only remaining question is whether the Veteran has PTSD as a result of his verified stressor, further discussion of the recent revisions to 38 C.F.R. § 3.304 is unnecessary. Diagnoses of PTSD must be rendered in accordance with the diagnostic criteria for the condition set forth in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). See 38 C.F.R. § 4.125 (noting that VA has adopted the nomenclature of the DSM-IV). Considering the claim for service connection in light of the above, the Board finds that competent, probative evidence establishes that the Veteran does not meet the diagnostic criteria for service-related PTSD, and that, therefore, the claim must be denied. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board finds that the VA psychologist's finding that the Veteran did not meet the full criteria for a PTSD diagnosis, is the most probative medical opinion on this point. The psychologist's diagnosis was based upon full consideration of the Veteran's service and post-service records, including the Veteran's credible assertions, as well as supported by a very thoroughly stated rationale. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); Gbrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). The psychologist also considered the private treatment records and discussed the problems with the diagnoses of PTSD contained in those records (for example, the PTSD "diagnoses" appeared to be from the Veteran's self-report that he had PTSD). Thus, the Board accepts this opinion as probative evidence on the question of a current PTSD diagnosis. In regard to the private treatment reports diagnosing PTSD, the Board finds that such diagnoses were based on the Veteran's self-diagnosis, which lacks competency, and on the Veteran's descriptions of his stressors, which lack credibility. The Board additionally notes these diagnoses do not conform to the DSM-IV criteria. While the Veteran reported at his January 2008 intake that he killed two children and an adult in Iraq, the record reflects that the Veteran reported to the VA examiner that he witnessed these deaths but did not kill children and a woman. Further, on the Veteran's post-deployment questionnaire, he marked that he discharged his weapon but did not see any dead bodies when in Iraq. Based on the lack of discussion of the DSM-IV criteria for PTSD, the Veteran's lack of competency to diagnosed himself with PTSD, and the Veteran's inconsistent statements regarding his experiences in combat, the private diagnosis of PTSD must be afforded little, if any, evidentiary weight. As a medical opinion (or in this case, an opinion relating to the existence of a diagnosis of PTSD, partly based on the Veteran's own assertions) can be no better than the facts alleged by the Veteran, an opinion based on an inaccurate (or unsubstantiated) factual premise has limited, if any, probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Black v. Brown, 5 Vet. App. 177, 180 (1993). Consequently, because that the Veteran clearly failed to provide the private psychological associate with an accurate stressor history, the Board cannot attach any significant probative value to a medical diagnosis of PTSD that is clearly based on an inaccurate history. In short, the most persuasive medical opinion evidence weighs against the existence of a current diagnosis of service-related PTSD, and ultimately, the claim, for service connection for that claimed disability. As the preponderance of the competent evidence establishes that the first, essential criterion for service connection for PTSD-medical diagnosis of the disorder in accordance with the diagnostic criteria for the disorder-is not met, service connection for PTSD cannot be established, and the Board need not address the remaining criteria for service connection for PTSD. See 38 C.F.R. § 3.304(f). Finally, as for any direct assertions by the Veteran, his mother, and/or his representative that the Veteran meets the diagnostic criteria for PTSD, such evidence provides no basis for allowance of the claim. As indicated above, the fundamental matter upon which this claim turns-a competent diagnosis of service-related PTSD-is within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran, his representative, and his family members are not shown to be other than laypersons without the appropriate medical training and expertise, none is competent to render a competent diagnosis of PTSD. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, the lay assertions in this regard have no probative value. For all the foregoing reasons, the Board finds that the claim for service connection for PTSD must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Personality Disorder Personality disorders are not considered "diseases or injuries" within the meaning of applicable legislation and, hence, do not constitute disabilities for VA compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9, 4.127 (2010). Therefore, to the extent post-service records show the Veteran has been diagnosed with a personality disorder, the Board finds that service connection for such a condition is legally precluded. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). ORDER Service connection for PTSD is denied. Service connection for a personality disorder is denied. REMAND The Board's review of the claims file reveals that further RO action on the claim remaining on appeal is warranted. As previously noted, the Veteran has been diagnosed with anxiety, NOS. On December 2009 VA examination, the psychologist found that the Veteran's anxiety more likely than not existed prior to his military service. The psychologist also found that the Veteran's current anxiety did not appear to be caused by being in the military although it may be that his current anxiety was exacerbated by his experiences being in the military in general. It did appear to the psychologist that the Veteran experienced anxiety about being in combat although he reported that he had no fear or being in combat and would prefer to be back in the military and in combat. The Veteran did not engage in avoidance and felt comfort from playing war-related video games. In a June 2010 addendum, the VA examiner additionally noted that the Veteran's present anxiety, interpersonal difficulties, vocational problems, and behavioral problems related to his personality disorder NOS that existed prior to military service. The psychologist noted that the Veteran was highly anxious, had these pre-existing problems, and poor coping skills, and it was therefore likely that the Veteran's anxiety was exacerbated while serving in the military and being exposed to combat (although, the Veteran identified his greatest stressor in the military as the divorce and his grandmother's death). Because the Veteran's pre-existing problems were so significant, however, the psychologist could not determine how much of his current anxiety was solely due to his military experience without resort to mere speculation. The psychologist noted that he did not believe that the Veteran's anxiety was caused by his military experience. He found that it was likely that the Veteran's anxiety was exasperated by his military experience and being in combat (as well as his anger about the divorce, not getting leave for his grandmother's death, and his sexual assault charges), however, because the Veteran's pre-existing problems were so significant, the psychologist found it impossible to determine how much of an additive effect his being in combat had on his already significant levels of anxiety, without resort to mere speculation. The psychologist readjusted the assigned GAF score to 51. The Board finds three problems with the examiner's opinion. First, while the examiner found that the Veteran's anxiety pre-existed service and was aggravated during service, he did not opine as to whether the Veteran's anxiety was aggravated beyond the natural course and scope of the disorder. A pre-existing injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(a) (2010). The underlying disorder, as opposed to the symptoms, must be shown to have worsened in order to find aggravation. See Hunt v. Derwinski, 1 Vet. App. 292 (1991). Second, the examiner relied on the Veteran's statements that he found to be inaccurate and incredible. For example, the examiner found that the Veteran's combat aggravated his anxiety, yet in the next sentence, the examiner noted that the Veteran's stated greatest stressor had nothing to do with his deployment. In fact, the psychologist repeatedly noted that the Veteran enjoyed combat and sought comfort from video games simulating combat. Additionally, on his post-deployment health assessment, the Veteran marked that he never felt that he was in great danger of being killed, and he denied any psychiatric problems related to combat. The Veteran's service treatment records contain no indication that he suffered from anxiety during service. Here, the examiner did not discuss the Veteran's specific denials of psychiatric symptoms on his post-deployment health questionnaire or point to any evidence of record establishing that the Veteran exhibited symptoms of anxiety in service. Third, as previously noted, the Veteran served on active duty from June 1999 to July 2005, however, only the period from June 24, 1999 to August 30, 2004 is considered honorable for VA purposes. The psychologist, however, considered the Veteran's full period of service in developing his opinion. Specifically, he noted that the Veteran's anxiety was aggravated by service, to include combat, his divorce, the death of his grandmother, and the sexual assault charges. Most of these events occurred after August 30, 2004. Because the examiner considered a period of service that is not considered honorable for VA purposes, a new examination is required. Accordingly, the RO should arrange for the Veteran to undergo VA psychiatric examination, by an appropriate psychologist or psychiatrist, at a VA medical facility. The Veteran is hereby advised that failure to report to the scheduled examination, without good cause, may result in denial of the claim for service connection (as the original claim will be considered on the basis of the evidence of record). See 38 C.F.R. § 3.655 (2010). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to the scheduled examination, the RO should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the date and time of the examination sent to him by the pertinent medical facility. Prior to arranging for the Veteran to under examination, to ensure that all due process requirements are met, and that the record before the examiner is complete, the RO should give the Veteran another opportunity to provide information and/or evidence pertinent to the claim remaining on appeal. The RO's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2010) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2010). The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claim remaining on appeal. In adjudicating the claim, the RO should particularly consider all evidence added to the claims file since the RO last adjudicated the claim, to include, for the sake of efficiency, that submitted to the Board in April 2011, notwithstanding the waiver of initial RO consideration of the evidence. Accordingly, this matter is hereby REMANDED to the RO, via the AMC, for the following action: 1. The RO should send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claim remaining on appeal that is not currently of record. The RO should also clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, the RO should assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO should notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses received from each contacted entity have been associated with the claims file, the RO should arrange for the Veteran to undergo psychiatric examination, by an appropriate psychologist or psychiatrist, at a VA medical facility. The entire claims file, to include a complete copy of the REMAND, must be made available to the physician designated to examine the Veteran, and the report of examination should include discussion of the Veteran's documented medical history and assertions. All appropriate tests and studies should be accomplished (with all results made available to the examining physician prior to the completion of his or her report), and all clinical findings should be reported in detail. The psychologist or psychiatrist should clearly identify all current psychiatric disability(ies) other than PTSD (to include previously diagnosed anxiety, NOS). Then, with respect to each such diagnosed disability, the physician should offer an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability), that the disability had its onset in or is otherwise medically related to service (noting that for VA benefit purposes, the Veteran's service is limited to only the period from June 24, 1999 to August 30, 2004). If any current psychiatric disability disorder ia found to have pre-existed service, the psychologist or psychiatrist should also offer an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability), that the disability was aggravated (beyond the natural course and scope of the disorder) by active duty service. In rendering the requested opinion(s), the physician should specifically consider and discuss the in- and post-service treatment records, as well as the Veteran's contentions. In particular, the examiner should comment on the opinions expressed in the December 2009 VA examination and June 2010 addendum opinion. The psychologist or psychiatrist should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed (typewritten) report. 4. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. 5. To help avoid future remand, the RO must ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the claim for service connection for psychiatric disability other than PTSD in light of all pertinent evidence (to include all that added to the record since the RO's last adjudication of the claim) and legal authority. 7. If the benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The appellant need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims 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 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs