Citation Nr: 1326534 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 07-06 466A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), bipolar disorder, and depression. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his son ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active military duty from April 1968 to November 1970. The appeal comes before the Board of Veterans' Appeals (Board) from January and September 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board in an April 2011 decision reopened the previously finally denied claim for service connection for PTSD on the basis of new and material evidence, and also then expanded the claim to include other psychiatric disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board then remanded the reopened claim for additional development. In December 2012 the Board remanded the claim again based on the Veteran's request for a Travel Board hearing. In June 2013, the Veteran was afforded a Travel Board hearing, conducted at the RO, before the undersigned Acting Veterans Law Judge. He was also previously, in February 2008, afforded a hearing before a Decision Review Officer (DRO) at the RO. Transcripts of both these hearings are contained within the record (which includes both the Veteran's physical claims file and his Virtual VA file). The case now returns to the Board for further review. FINDING OF FACT The Veteran does not suffer from an acquired psychiatric disability that can be related to his period of service. CONCLUSION OF LAW The criteria for service connection for any psychiatric disorder, including PTSD and bipolar disorder and depression and alcohol dependence and any alcohol-induced psychiatric disability, are not met. 38 U.S.C.A. §§ 105, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.1(n), 3.301, 3.303, 3.304(f) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) . This notice must be provided prior to an initial decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the decision of the U.S. Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006) requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by re-adjudication of the claim, as in a Statement of the Case (SOC) or Supplemental Statement of the Case (SSOC). Where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has held that an error in VCAA notice should not be presumed prejudicial, and that the burden of showing harmful error rests with the party raising the issue, to be determined on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). In this case, the appellant has not demonstrated and the evidence of record does not show any prejudicial or harmful error in VCAA notice. VA has fulfilled the above requirements in this case for the claim for service connection for an acquired psychiatric disorder, to include PTSD, bipolar disorder, and depression. A VCAA notice letter was sent in April 2005. This letter addressed the claim as then styled (a request to reopen a claim for service connection for PTSD) and was sent prior to the appealed January 2006 RO adjudication of the claim for service connection for PTSD. The Board finds that this VCAA letter adequately addressed the evidence required to support both the request to reopen and the underlying claim for service connection for PTSD on the merits. Kent v. Nicholson, 20 Vet. App. 1 (2006). The letter further notified of the existence of certain presumptions by which service connection for a disability may be afforded a claimant. The VCAA letter informed the Veteran of the notice and duty-to-assist provisions of the VCAA, the bases of review, and the information and evidence necessary to substantiate the claim. He also was informed by this letter that it ultimately was his responsibility to see that pertinent evidence not in Federal possession was obtained. The Veteran was afforded Dingess notice by a May 2011 VCAA letter which also then addressed the expanded claim for service connection for an acquired psychiatric disorder, to include PTSD, bipolar disorder, and depression, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). This was followed by the Appeals Management Center (AMC) issuance of a SSOC in July 2012 appropriately addressing the expanded claim. The subsequent Board remanded in December 2012 solely required affording the Veteran the opportunity of a Travel Board hearing. The undersigned Acting Veterans Law Judge conducted that hearing in June 2013. While the Veteran subsequently submitted a June 2013 medical opinion letter supportive of his claim, he then expressly waived RO review of the additional evidence prior to Board adjudication of his claim. The April 2005 and May 2011 letters also requested that the Veteran advise of any VA and private medical sources of evidence pertinent to his claim and that he provide necessary authorization to obtain those records. They requested evidence and information about treatment after service in support of the claim. Based on information provided by the Veteran, post-service treatment records were obtained from VA sources. These records were associated with the claims file. In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2012) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the Board hearing conducted in this case, the undersigned outlined the issues on appeal and suggested that any evidence tending to support the claim that had not yet been submitted should be, which necessarily included in this case evidence of a causal link between the claimed psychiatric disability and the Veteran's period of service. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. The Veteran was informed appropriately of records obtained, including by the currently appealed rating decision, an SOC, and SSOCs, including most recently in July 2012. He also was informed of records not obtained, the importance of obtaining all relevant records, and his responsibility to see that records are obtained in furtherance of his claim. In the absence of any report or indication of additional records not yet obtained relevant to the appealed claim, VA need not assist the Veteran in obtaining additional records and need not seek to obtain any for association with the claims file prior to the Board's adjudication of the currently appealed claim. As delineated in 38 C.F.R. § 3.159(c)(4), a VA examination to address the question of etiology as related to service is required when a Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded a VA examination for compensation purposes in January 2010 to address his claim for service connection. The examination considered PTSD and found a diagnosis not support, but also addressed questions of diagnosis and etiology of any other psychiatric disability. The Board finds that the January 2010 examination sufficiently addressed the medical questions of diagnosis and etiology of claimed psychiatric disabilities, with due consideration of the entire evidentiary record, lay statements, and relevant medical knowledge. This examination report also provided analyses based on review of all the evidence of record, inclusive of clinical records and past examination records within the claims file, and relevant tests or studies, and included opinions supported by this analysis with satisfactory rationale sufficient to be weighed against contrary evidence. The Board finds that the January 2010 examination, taken together with the balance of medical and non-medical evidence of record, provides sufficient detail and sufficient medical evidence and findings to allow for appropriate Board adjudication of the claim on appeal adjudicated herein. 38 C.F.R. § 4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In view of the foregoing, the Board finds that no further notice or assistance to the appellant is required to fulfill VA's duty to assist in the development of the currently appealed claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. at 183. Neither the Veteran nor his representative has presented any avenues of evidentiary development which have a reasonable possibility of furthering the claim. Hence, the case presents no reasonable possibility that additional evidentiary requests would further the currently appealed claim. 38 U.S.C.A. § 5103A (a)(2); 38 C.F.R. § 3.159 . The Veteran has submitted lay statements in support of this claim. He also provided testimony before a DRO hearing and before the undersigned at a Travel Board. There is no indication that the Veteran desires a further opportunity to address his claim. The Board also finds that the development required by the prior Board remands has been substantially accomplished. The April 2011 remand required notice, development, and RO or AMC consideration of the expanded claim for service connection for an acquired psychiatric disorder. The December 2012 remand required the Travel Board hearing afforded the Veteran in June 2013. All of this was substantially accomplished. Only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97 (2008). In view of the foregoing, the Board finds that all notification and development actions needed to render a decision on the Veteran's currently appealed claim have been accomplished. II. Claim for Service Connection for an Acquired Psychiatric Disorder, To Include PTSD, Bipolar Disorder, and Depression Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. Disorders diagnosed after discharge may still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. To establish service connection for a disability, a claimant must submit (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Pond v. West, 12 Vet. App. 341, 346 (1999). However, service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). 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). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The establishment of service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., DSM-IV); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that 38 U.S.C.A. § 105 and § 1110 preclude compensation for primary alcohol abuse disabilities and secondary disabilities that result from primary alcohol abuse. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). The decision explains that "primary alcohol abuse" means an alcohol abuse disability arising during service from voluntary and willful drinking to excess. Id. However, the Federal Circuit has held that service connection is warranted when drug or alcohol abuse results secondarily from a service-connected disability, but compensation should only result "where there is clear medical evidence establishing that the drug or alcohol abuse disability is indeed caused by the veteran's primary service-connected disability." Id at 1371-1381. While medical evidence may be required to address questions of diagnosis or causation specifically requiring medical expertise, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability which may reasonably be observed by laypersons. See 38 C.F.R. § 3.303(a). The Federal Circuit Court has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a disability when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical profession." Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009) ("in some cases, lay evidence will be competent and credible evidence of etiology"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 496 (1997), citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994), (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996). In this, as in any other case, it remains the duty of the Board as the fact finder to determine the relative credibility of the evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). The Federal Circuit has held that the Board is obligated to, and fully justified in, determining whether lay testimony is credible in and of itself, and that the Board may weigh the absence of contemporary medical evidence against lay statements. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in doing so, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998). The Board cannot make its own independent medical determination, and it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. The Board has an obligation to provide reasons and bases supporting this decision, but there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Over the course of his appeal, at his two hearings, in submitted written statements, and in narratives provided to treating mental health clinicians as well as a January 2010 VA examiner for compensation purposes, the Veteran related numerous incidents he experienced while serving in Vietnam, which he has at times characterized as 'war stories.' He also related an ongoing situation of sexual harassment by a superior in Vietnam which ultimately reportedly led to that superior raping the Veteran, apparently while the Veteran was compromised by alcohol. The Veteran also provided a statement by a fellow soldier corroborating two incidents, one involving a fellow soldier being killed when struck in the head by a helicopter blade, and one in which a Vietnamese child was run over by a truck and killed. The fellow soldier asserted that both he and the Veteran were present and witnessed both of these incidents. The Veteran has also submitted records by treating VA medical personnel with assessments of PTSD based on combat stressors. Additionally, in June 2013 (with waiver of RO review), the Veteran submitted a letter by a treating physician, whom the Veteran has identified as working for VA. That physician, J. H., in that letter also diagnosed the Veteran with PTSD. While the Veteran asserted at his hearing before the undersigned that unit or morning reports would help corroborate incidents alleged to have occurred in service, that is ultimately not relevant to the present determination, and hence the Board has found that any such additional inquiry is not warranted, principally because the Board finds that current medical evidence is sufficiently informative of the absence of an Axis I disorder other than alcohol dependence or alcohol abuse, and that questions of a link to incidents in service are rendered moot. The Veteran's service medical records and service personnel records are already contained within the claims file. These show no psychiatric difficulties during service, and no findings of psychiatric difficulties upon service separation examination. Upon VA psychiatric examination for compensation purposes in January 2010, the Veteran was noted to have been accompanied by his adult son. The examiner reviewed the Veteran's file inclusive of medical records, and noted a history of VA treatment for diagnosed PTSD as well as alcohol dependence, with an additional diagnosis of "bipolar" or "bipolar II" reflected in these treatment records. Current prescribed medication was noted to include an antidepressant. The record was noted to reflect group therapy but not individual psychotherapy. The examiner observed that the Veteran's military occupational specialty (MOS) was clerk typist, but that the Veteran reportedly had exposure to combat in Vietnam. The Veteran endorsed at the examination that he began drinking alcohol every night in Vietnam "enough to get a buzz and go to sleep." The January 2010 examiner noted the Veteran's history of four past marriages, none lasting more than two and a half years, with the Veteran attributing the termination of these marriages to his having been in Vietnam; however, he did acknowledge that "being an alcoholic had something to do with it." The Veteran reported having a "lousy" relationship with his daughter but a "fantastic" one with his son. The Veteran described himself as a loner, but admitted that he met with other veterans once a week and also sometimes went fishing with them, endorsing fishing as a leisure pursuit. Additionally, although the Veteran asserted that he had very little social interaction or social support, the examiner noted that the Veteran had brought his son with him, and that the Veteran had discussed interacting with other veterans on a regular basis. This examiner observed that the Veteran was clean, neatly groomed, and appropriately and casually dressed, with speech, psychomotor activity, thought processes, and thought content all unremarkable; affect normal; attention intact; and mood good. The Veteran presented to the examiner as cooperative, friendly, relaxed, and attentive. The Veteran demonstrated judgment, insight, and average intelligence, with no delusions, hallucinations or inappropriate behavior. The January 2010 examiner made careful observations of the Veteran with regard to the Veteran's self-reported significant problems with startle response and hypervigilance, noting that neither of these were demonstrated at the examination, with the Veteran seated with his back to an open doorway, and the examiner entering the room from behind the Veteran three times yet eliciting no startle response. The examiner also made careful observation that the Veteran demonstrated "no obvious signs of anxiety or hypervigilance." The examiner noted that upon testing "not once did he even turn around or remove his attention from the computer screen" despite being seated with his back to the open doorway, thus causing the examiner to emphasize that on no occasion did the Veteran "appear to be startled in any manner." The examiner noted that despite these observations of the Veteran at the interview, the Veteran asserted that he "always" sits with his back to the wall and does not like having things behind him. The examiner noted that the Veteran spent much of the examination interview retelling narratives of incidents in service which the Veteran characterized as "war stories." The Veteran self-reported having felt "intense fear and horror" during more than one of these wartime episodes. Additionally, the Veteran endorsed having all noted symptoms of PTSD "every night" or "every day" or "all the time," and that he was "never" free of his symptoms, which he alleged were persistent since his return from Vietnam. However, when the examiner questioned the presence of relevant elements of specific symptoms of PTSD related to his Vietnam service, the Veteran's responses did not support the presence of the symptoms. For example, when asked to address things he avoided or did not like, he reported on multiple things but nothing related to his Vietnam experiences. When asked about endorsed recurrent or intrusive recollections, once again he failed to report his service experiences. Upon administration of psychological tests, the examiner noted that upon the MMPI-2 the degree of psychopathology the Veteran reported experiencing was unusual "even in a clinical population." While noting that it was always possible that the Veteran's over-endorsement of symptoms was a "cry for help," the examiner concluded it "quite likely that there was some intentional exaggeration of the current symptom picture, possibly for secondary gain issues." On the basis of this over reporting, the examiner found testing to be invalid, and clinical interpretation of the test results was not indicated. The examiner further noted that the PCL-M and Mississippi scales had a "high degree of face validity (i.e., the person taking the test knows what is being measured)" and were thus "susceptible to exaggeration of the symptoms being measured." The examiner thereby concluded that the results of these scales were also "more likely than not invalid as measures of his current functioning." The examiner concluded that the Veteran did not meet the diagnostic criteria for a diagnosis of PTSD, but did warrant a diagnosis of alcohol dependence. Addressing past diagnoses and current findings, the examiner noted that while the Veteran replied affirmatively to closed-end questions of the presence of PTSD symptoms, he did not provide "credible responses" to requests for examples, and psychological testing similarly indicated "overendorsement of symptoms." The examiner noted that the Veteran has a documented history of chronic alcohol abuse, and that symptoms of sleep impairment and mood difficulties were likely the result of this alcohol abuse. The examiner further found no evidence in the historical record that the diagnostic criteria for previously diagnosed bipolar disorder were met. Rather, the examiner concluded, "previously noted symptoms are all accounted for by the abuse of alcohol and not an underlying bipolar disorder." Ultimately, the Board finds that the weight of the evidence is against the Veteran having PTSD due to any in-service stressor, and is against the Veteran having any other psychiatric disability causally related to service. In arriving at this conclusion, the Board relies heavily on the VA psychiatric examination for compensation purposes conducted in January 2010, the psychological testing with validity testing conducted for that examination, and the findings and conclusions of that examiner based on medical analysis relying on the Veteran's assertions of symptoms as well as his wartime narratives, but also the Veteran's presentation at that examination, with the overwhelming weight of the substantial evidence derived from that examination to the effect that the Veteran does not have PTSD, is not credible in his statements in support of his claim, and does not suffer from psychiatric disability related to service. While the record contains numerous diagnoses of PTSD by treating mental health practitioners and social workers or other clinicians, these have relied upon the Veteran's self-report of symptoms and stressors, without validity testing of self-reported symptoms, or otherwise represent a diagnosis carried forward from a prior assessment. In contrast, at the Veteran's January 2010 VA examination, as discussed above, the examiner addressed the significant over-reporting of symptoms upon psychological testing, the Veteran's over-endorsement of symptoms upon examination interview, and the Veteran's contradiction of his self-reported symptoms and self-reported extent of such symptoms by his presentation at that examination and by his responses to more open-ended questions in the examination interview. Such a careful evaluation of the validity of self-reported symptoms is not shown in the treatment records, thus strongly supporting the January 2010 VA examiner's conclusion that past diagnoses based on such self-reported symptoms, including PTSD but also of bipolar disorder, were erroneous. Rather, the Board finds convincing the sound reasoning and judgment of the January 2010 examiner - based on careful review of the evidence presented including false or exaggerated presentations of symptoms and a long history of alcohol dependence and abuse with associated attributable psychiatric symptoms - that presenting symptoms such as are objectively supported, including depressive symptoms, are all, by the preponderant weight of the evidence, explainable as aspects or effects of the Veteran's well-documented alcohol dependence and alcohol abuse. The Board has also carefully considered the letter submitted in June 2013 by treating VA physician J.H., M.D., whom both the Veteran and this treating physician have conceded not only has been the Veteran's treating physician in recent years, but also has been a friend of the Veteran for in excess of 20 years. This physician asserts that the VA examination assessing the Veteran for purposes of his claim may be inaccurate due to the examination being conducted in a "referent manner" without the benefit of a patient advocate accompanying the Veteran at the examination. The physician J.H. also asserts that the Veteran may have become "flustered" when responding to questions in the examination interview "when frustrated with his cognitive disabilities." However, the VA examination in January 2010 was careful to observe the Veteran's demeanor and presentation, and observed him to be engaged, relaxed, and with goal-directed thinking, without observed current cognitive impairments as would interfere with his reporting of symptoms of disability. In short, the January 2010 examination report affords no evidence of, and in fact contradicts, such an assertion of the Veteran becoming so flustered so as to affect his responses upon psychological interview. Dr. J.H., in the June 2013 letter, makes much of his many past treatments of the Veteran, and of his past observation of the Veteran, noting, "In addition to [the Veteran's] cognitive impairments, noting the DSM-IV Diagnostic Criteria for PTSD, I recognize all the persistent symptoms of increased arousal to be operant." However, J.H. failed to address specifically the presence of PTSD-related hyperarousal, such as exaggerated startle response. To the contrary, the January 2010 examiner did not discount the potential presence of hyperarousal such as when intoxicated, but did reject the presence of ongoing startle responses supportive of the presence of PTSD. Additionally, the June 2013 letter entirely fails to address the overriding credibility questions presented at the January 2010 examination, including exaggerating symptoms of disability or the Veteran endorsing ongoing symptoms of disability which are demonstrably not present, giving rise to erroneous diagnoses by treating medical or mental health practitioners when such self-reported symptoms are accepted by these practitioners. Physician J.H's failure to address this issue when defending a diagnosis of PTSD as against such findings as were made upon the January 2010 examination leads the Board to conclude that this physician most likely also relied upon the Veteran's self-reporting, without the benefit of more objective testing. It is sufficient for the Board to conclude that the absence of validity testing on the part of this physician reduces significantly the probative weight of his assessment of the Veteran's condition. As already noted, the Board concludes that the Veteran's self-report of his symptoms of disability such as PTSD or other mental illness are lacking in credibility, based on his over-reporting or over-endorsement of symptoms including upon psychological testing, and based on his contradiction of reported symptoms by clinical presentation upon examination. Caluza. Thus, the Board finds that these self-reported symptoms and the many clinical assessments by treating physicians or other mental health clinicians based on these self-reported symptoms are not probative for purposes of the Board's adjudication, and hence may not serve to support the claim. A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board has also duly considered the Veteran's statements in support of his claim, including statements beyond endorsement of symptoms of disability and history of in-service events. While the Veteran asserted at times in treatment records that he turned to alcohol as a result of symptoms of anxiety or depression, the January 2010 VA examiner attributed such symptoms themselves to the Veteran's alcoholism. The medical or psychological examiner bears the expertise for such attribution, while such cause-and-effect questions between psychiatric disability, in this case alcoholism and alcohol abuse, and symptoms of disability, are beyond the ambit of lay knowledge, and thus the Veteran is not competent to address them in support of his claim. Jandreau. The Veteran's over-reporting of symptoms may also potentially reflect characterological or personality disorders, and indeed a characterological or personality disorder has also been identified in the clinical record, which cannot be service-connected. See 38 C.F.R. § 3.303(c) (2012). The Board herein finds the preponderance of competent, credible evidence to be in accord with and supportive of the January 2010 VA examiner's conclusions that the Veteran does not have PTSD and does not have another Axis I psychiatric disorder, other than alcohol dependence, and has not in the past had psychiatric disability other than that stemming from his alcohol dependence or alcohol abuse. The preponderance of the evidence is thus against the claim for service connection for an acquired psychiatric disorder, to include PTSD, bipolar disorder and depression, with none of these being present during the claim period. 38 C.F.R. §§ 3.303, 3.304(f); McClain. Service connection for alcohol dependence is barred in this case, the weight of the evidence in this case being against alcohol abuse being due to other disability, including against it being due to other psychiatric disability. See 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995) (permissibility of service connection for alcoholism as secondary to other service-connected disability). Because the Board finds the weight of the evidence supportive of the January 2010 VA examiner's conclusion that the Veteran's psychiatric difficulties stem from his alcohol abuse and alcoholism, rather than alcohol abuse or alcoholism resulting from other psychiatric disability, the Board finds that the Veteran's alcoholism and associated psychiatric symptoms are barred from service connection, and are deemed not to have been incurred in service. See 38 C.F.R. § 3.301 (2012) (bar to direct service connection for alcohol abuse). After carefully weighing all the medical and lay evidence of record and because the preponderance of that evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the claim for service connection must be denied. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, bipolar disorder, and depression, is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs