Citation Nr: 1338342 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 07-11 876 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) due to military sexual trauma. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1981 to February 1986. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. During the pendency of the appeal, the Veteran's claims file was transferred to the jurisdiction of the RO in Cleveland, Ohio. This case was remanded for further development in January 2011, January 2013, and June 2013. The remand directives have been substantially completed, and the claim is again before the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). A review of Virtual VA reveals that it contains VA treatment records relevant to the issue on appeal. Further, this appeal was processed using the Veterans Benefits Management System paperless claims processing system. Accordingly, any future consideration of the appellant's case should be applied to this electronic record. FINDINGS OF FACT 1. The preponderance of the competent and probative evidence of record is against finding that the Veteran meets the diagnostic criteria for a diagnosis of PTSD. 2. The preponderance of the evidence shows a personality disorder was present in and most likely before service, and fails to reveal the onset of an acquired psychiatric disorder during service. 3. The preponderance of the evidence is against finding that the Veteran has a psychiatric disorder that is related to active military service or events therein. 4. There is no evidence of that a psychosis manifested to a compensable degree within one year from the date of termination of active duty. 5. Personality disorders are not diseases or injuries subject to compensation payments. CONCLUSION OF LAW An acquired psychiatric disability, to include PTSD due to military sexual trauma, was not incurred in or aggravated by service, and a psychosis may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1111, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a 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 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; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in a November 2008 letter the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims, including what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. In the January 2011 Board remand and subsequent Appeals Management Center February 2011 correspondence, the Veteran was asked to provide any additional alternate evidence verifying the occurrence of Military Sexual Trauma (MST), including statements from family and friends. A March 2013 supplemental statement of the case also advised the Veteran to submit evidence from medical providers, statements from others who could describe their observations of her disability level, and her own statements describing the symptoms, frequency, severity and additional disablement caused by her disability and the effect that the disability has on her employment, and also provided examples of pertinent medical and lay evidence that she may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The case was last adjudicated in August 2013. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment records, private treatment records, VA treatment records, the reports of VA examinations, and personal statements of the Veteran. The Veteran has not identified any other relevant records or evidence that have yet to be acquired by VA and associated with the claims file. In sum, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate her claim, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Thus, the Veteran was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Relevant Laws and Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and a psychosis becomes manifest to a degree of 10 percent within one year from date of termination of active duty, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128 (1997). The diagnostic criteria, including those related to stressors, set forth in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM-IV) for mental disorders have been adopted by the VA. 38 C.F.R. § 4.125 (2013). A diagnosis of PTSD requires exposure to a traumatic event and a response involving intense fear, helplessness, or horror. A stressor involves exposure to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror. See Cohen, 10 Vet. App. 128. The sufficiency of a stressor is a medical determination and is presumed by a medical diagnosis of PTSD. Id. The evidence necessary to establish the occurrence of a stressor during service to support a diagnosis of PTSD will vary depending upon whether a veteran engaged in "combat with the enemy" as established by official records. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Dizoglio v. Brown, 9 Vet. App. 163, 164 (1996); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). For stressors unrelated to combat, credible supporting evidence is necessary in order to grant service connection. "Credible supporting evidence" of a noncombat stressor may be obtained from service records or other sources. Moreau v. Brown, 9 Vet. App. 389 (1996). The Court has held that the regulatory requirement for "credible supporting evidence" means that "the appellant's testimony, by itself, cannot, as a matter of law, establish the occurrence of a noncombat stressor." Dizoglio, 9 Vet. App. 163. Therefore, the appellant's lay testimony is insufficient, standing alone, to establish service connection. Cohen, 10 Vet. App. at 147 (citing Moreau, 9 Vet. App. at 395). With respect to the Veteran's allegations of personal assault/MST, the Board notes that there are special considerations for PTSD claims predicated on a personal assault. The pertinent regulation, 38 C.F.R. § 3.304(f)(5), provides that PTSD based on a personal assault in service permits evidence from sources other than a veteran's service records which may corroborate his or her account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). The VA M21-1MR guide also identifies alternative sources for developing evidence of personal assault, including private medical records, civilian police reports, reports from crisis intervention centers, testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, and personal diaries or journals. M21-1MR, Part IV, Subpart ii, 1.D.17.g. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance, substance abuse, episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(5). VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. In addition, VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). When all relevant evidence has been obtained, it is the Board's principal responsibility to assess the credibility, and therefore the probative value of proffered evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429, 433 (1995). In determining whether documents submitted by a claimant are credible, the Board may consider internal consistency, plausibility, and consistency with other evidence submitted on behalf of the appellant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The law provides, however, that the Board is not required to accept an appellant's uncorroborated account of his active service experiences. See Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). The benefit of the doubt rule provides that an appellant will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the appellant prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background The Veteran contends that she currently has PTSD or other psychiatric disorder related to sexual assault and harassment which occurred during service. The Veteran has submitted statements describing how she endured years of "stalking" and "constant" harassment. In statements to VA, the Veteran reported a 1981 incident which she describes as her most severe stressor event, stating that a man had sat on her bed, saying "disgusting things" and attempting to have sex with her, causing her to run into the bathroom and bolt the door. She wrote that "the guy was pounding on the door saying he was going to break it down. I was panicking, trembling, I opened the bathroom window and climbed out and went and stayed in another barrack." The Veteran stated that she was "petrified" and considered "getting out" of the service because of this event. The event upset her so much she took 3 days of emergency leave, which is not mentioned in her service records but has been supported in statements submitted in February 2007 by her mother and sister. The Veteran has also described an incident where a male drill sergeant took her military ID and questioned her for 4-5 minutes in a manner than made her "very uncomfortable" and scared. In a third incident, the Veteran described being told by a male soldier that he would rape her that night. Lastly, the Veteran described finding a man hanging from his fingers outside of her barracks window. She stated that this was when her "nerves really took off," and that from that time she began to have stomach problems, dizziness, nervousness, and shaking. In a statement submitted to VA in December 1996, the Veteran stated that while stationed in Hawaii, another soldier stalked and harassed her. The Veteran's service treatment records include several references to psychological issues. A December 1980 entrance examination indicates a prior history of "nervous trouble of any sort," and the history summary includes "nervous stomach." In September 1982 the Veteran reported feeling dizziness, nervousness, and vision problems. In October 1982 the Veteran reported having dizzy spells occurring at night and associated with pre-sleep or awakening from sleep, and also associated with tremors, hallucinations such as seeing things jump across the room, and hearing music or voices. The examiner's assessment was that stress or psychological factors were probably the cause of her symptoms. A May 1985 service treatment records indicated possible anxiety and a referral to psychiatry after the Veteran complained of dizziness and abdominal pain. A later May 1985 treatment record indicated that the Veteran did not feel that psychological stress was causing her physical problems and that she had been experiencing marital dysfunction. Another May 1985 treatment record indicates that the Veteran could have physiological factors affecting physical condition and psychosexual problems. The Veteran's January 1986 separation examination notes no nervous trouble of any sort. The Veteran's personnel records do not show any incidents related to sexual assault or harassment. In March 2011 the Appeals Management Center contacted the U.S. Army Crime Records Center for verification of the claimed reported assault in 1983, but in April 2011 was informed that there was no record of the incident. The Veteran first applied for entitlement to service connection for "nerves" in February 1986, but the claim was denied because she failed to attend her scheduled VA examination. In December 1996 the Veteran submitted a new claim for a mental health disorder. The Veteran was afforded a VA examination in August 1997. The examiner reviewed the claims file and additional medical records provided by the Veteran. The examiner discussed the Veteran's history and noted that she was currently receiving treatment for her nerves and that she had been previously diagnosed with dysthymia. The Veteran reported that she had been taking Xanax since 1981 and reported having obsessive compulsive disorder, but the examiner noted she did not show any symptoms of obsessive-compulsive features. The Veteran reported having had suicidal thoughts in the past and that before taking medication, she had depression and mood swings. She also reported feeling a lot of stress when she was sexually harassed in the Army and that she was once almost raped, but that her commanding officer wouldn't do anything about it. The examiner diagnosed the Veteran with dysthymic disorder with anxiety features and alcohol dependence. In a November 1997 rating decision, the Veteran was denied service connection for a nervous condition because the condition was not shown to be incurred in or caused by service. The Veteran submitted the current claim on appeal in February 2005. The Veteran's VA treatment records show frequent complaints and treatment related to psychiatric disorders. In November 2000 the Veteran was treated for anxiety attacks. She reported that her first panic attack had been in 1981, that she had been given Valium at that time, and that she had taken Xanax sporadically from 1983 to 1992. She also reported that she had been "almost raped" twice in the military and that she had reported the harassment of one fellow soldier who was them dismissed from the military. She was diagnosed with generalized anxiety disorder, rule out panic disorder and major depressive disorder. In September 2001 she again reported that her panic attacks began while in the military and were associated with attempted sexual assaults. She also reported having intense fear related to her irritable bowel syndrome and a fear of voiding in public. She was diagnosed with possible organic affective disorder, rule out bipolar disorder and major depression with anxiety features. In December 2001 the Veteran attended an individual therapy session to address her panic attacks and intense fear of voiding in public. In April 2002 the Veteran was admitted for treatment related to recurrent major depression, currently in crisis with suicidal and homicidal features, due to a recent suicide attempt and fear of her abusive boyfriend. Upon admittance, the Veteran discussed her fear that her boyfriend would kill her, her thoughts of killing him, and her attempt to kill herself. She also reported that in the military a man had twice attempted to rape her. In May 2004 the Veteran received treatment for generalized anxiety disorder at the Mansfield Outpatient Clinic. In May 2002 the Veteran was admitted to the Highland Drive VA Medical Center for substance-induced mood disorder, alcohol abuse, benzodiazepine dependence and abuse, and history of major depression with anxious features and suicide gesture. The Discharge Summary described her primary stressor as her emotionally, physically, and sexually abusive boyfriend, and her past alcohol and drug abuse were also discussed. In November 2004 the Veteran discussed having been recently violently assaulted and badly injured in a bar and was noted to have exhibited some drug-seeking behavior. She was diagnosed with anxiolytic dependence, rule out bipolar disorder, and borderline personality disorder. In December 2004 the Veteran reported feelings of anxiety and that she believed her panic attacks had started around the time that she was "almost raped" 3 times in the military. She also reported that she was assaulted in October by someone she didn't know and that she was constantly afraid she would be attacked or killed by this assailant. The psychiatrist's assessment noted that the Veteran had longstanding anxiety symptoms that followed reported sexual assault in military and worsened after her more recent physical assault. The Veteran was diagnosed with PTSD and benzodiazepine abuse. In January 2005 she reported feeling depressed and hopeless and that she had recently "freaked out" after being groped at her job. At an MST counseling session that same day, she reported feeling frightened of a biker whom she had pressed charges against for the recent physical assault and discussed having been sexually harassed in the military. Several times in 2006 the Veteran reported problems with depression and anxiety. In September and November 2006 the Veteran reported having recently suffered a miscarriage and being severely beaten in 2004. She was diagnosed with adjustment disorder, anxiety, and depressed mood. In a January 2007 evaluation the Veteran reported feeling angry and anxious following past MST and the more recent violent assault. She was diagnosed with adjustment disorder, anxiety, depressed mood, and PTSD/MST. The Veteran attended regular MST counseling sessions in 2007, where she reported stress regarding the upcoming trial of the man who assaulted her in 2004 and nightmares of men who have assaulted her in the past, and she was diagnosed with adjustment disorder with mixed mood. In a July 2007 social work note, the Veteran reported feeling depressed and having serious problems with a physically and emotionally abusive partner. In April, June, and August 2007 the Veteran reported continued depressive and anxiety symptoms and was diagnosed with adjustment disorder, depressed mood, and PTSD/MST. In March 2008 the Veteran was admitted to the acute psychiatric ward due to active suicidal and homicidal ideation following abuse from her partner. The Veteran was diagnosed with adjustment disorder, depressed mood, and PTSD/MST by history. In a May 2008 psychiatric note the Veteran again reported personal problems and was diagnosed with severe major depressive disorder and PTSD/MST. In September 2008 the Veteran reported feeling suicidal. In an August 2009 psychiatric assessment, the Veteran reported serious personal problems and partner abuse, past suicidal and homicidal ideations, severe depression, and difficulty sleeping. She was diagnosed with major depressive disorder and PTSD/MST. The Veteran also indicated at this assessment that she was not interested in further PTSD/MST treatment at this time, and last that month informed the Lafayette Outpatient Clinic that she was moving to Ohio and would not be returning for any future medical appointments. The Veteran has also received psychiatric treatment from a number of private medical professionals. Private treatment records from Berlin Medical Clinic show that she first reported feeling nervousness in July 1989, and her treating physician found her to have anxiety. In January 1992 the Veteran requested medication for her nerves because she was starting back at work the next day, and in February 1992 she reported having a nervous stomach. The Veteran reported nervousness, dizziness, stress, and anxiety on several additional occasions in 1992 and 1993, and in July 1992 she was diagnosed with depression. From 1993 to 1997 the Veteran received psychiatric treatment for depression and anxiety at the Fairbanks Psychiatric and Neurology Clinic. In December 1993 she was diagnosed with dysthymia. In her November 1994 social worker initial evaluation, the Veteran reported having felt shaky, dizzy, and unable to think, and was diagnosed with dysthymia, rule out major depression, and alcohol abuse. A February 1995 letter from the Veteran's psychiatrist stated that since December 1993 the Veteran had been treated for depression, anxiety, and episodic misuse of prescription drugs and binge alcohol consumption. In an October 1995 letter, the Veteran's psychiatrist wrote that she "has had increasing troubles with depression and anxiety." The Veteran was also treated by a private psychologist at Personal and Family Counseling Service of T. Valley from 2009 to 2010. Throughout her counseling she reported experiencing anxiety, panic attacks, depression, nightmares, and negative thoughts associated with past sexual abuse. In December 2009 the Veteran reported that she had been sexually assaulted in basic training. In February 2010 she was diagnosed with mood disorder, panic disorder without agoraphobia, alcohol related disorder, sedative dependence by history, and personality disorder. In April 2010 the Veteran reported that her ex-boyfriend was threatening her. In October 2010 she stated that she had been abused by her ex-boyfriend and was bullied as a child, and because of this abuse she now has trust issues. In November 2010 the psychiatrist noted that he was showing paranoid ideation. The Veteran was separately treated for anxiety, depression, and attention deficit disorder by other private doctors on several occasions between August 2009 and December 2011. In a February 2010 psychiatric evaluation from Dr. N.M., the physician stated that the Veteran had previously experienced traumatic episodes including being raped twice in the military and that she now exhibited extremely fearful symptoms, along with depression and anxiety. She diagnosed the Veteran with bipolar disorder, panic with agoraphobia, alcohol abuse and sedative dependency by history, and chronic PTSD. In an evaluation provided to the Social Security Administration (SSA) in February 2011, Dr. N.M. discussed the Veteran's paranoia, fearfulness in public, and frequent agitation. She diagnosed the Veteran with bipolar disorder with psychotic features vs. psychotic disorder, chronic PTSD, anxiety disorder with agoraphobia, possible sedative abuse, and alcohol abuse in complete remission. The SSA found the Veteran to be disabled due to affective disorder and other disorder of the gastrointestinal system. In January 2013 the Veteran was afforded a VA psychiatric examination by a clinical psychologist. The examiner indicated that she had reviewed the claims folder, including the personal statements of the Veteran. The examiner stated that a November 1994 evaluation indicated that the Veteran had experienced periods of depression and having "breakdowns" since adolescence. The examiner also stated that the Veteran's entrance examination noted "nervousness," and that later service treatment records included notations of anxiety, psychosexual problems, and possible hallucinations, but no formal diagnosis or treatment for any psychiatric disorders. The examiner noted that the Veteran has received numerous different diagnoses since she began receiving psychiatric treatment in 1994, which she felt was due to her change in symptom presentation over time and was best explained with a diagnosis of borderline personality disorder, which would allow for such variable symptomatology. The examiner also diagnosed her with schizoaffective disorder. The examiner ultimately opined that the Veteran's personality disorder predated her service, and her symptoms from schizoaffective disorder did not begin until the death of her husband in 1993. The examiner stated that "while there is some indication of possible nervousness in service," there was no aggravation of her symptoms during service because she was able to function adequately while enlisted. The examiner also added that because borderline personality disorder is a lifelong disorder, "the military might have been a protective factor for her, given its structured environment." The examiner indicated that persons with borderline personality disorder may develop psychotic-like symptoms, such as hallucinations, during times of stress, which may account for the treatment report of hallucinations in service. The examiner described the Veteran's alleged stressors events during service, but found that they did not rise to the severity of ones that could support a diagnosis of PTSD as "traumatic events." The Veteran was afforded an additional VA examination in June 2013 by a clinical psychologist. The examiner reviewed the claims file and discussed the Veteran's personal and medical history. She discussed the Veteran's reported stressors of being threatened by several men during service, but noted that they did not meet the criteria required to support a diagnosis of PTSD. The Veteran reported having feelings of anxiety and frequent depression, as well as past cutting behavior and auditory hallucinations. The examiner found that the Veteran's symptoms did not meet the criteria for a diagnosis of PTSD, but instead diagnosed her with schizoaffective disorder, unrelated to military service, and alcohol dependence, in remission. Regarding the criteria for PTSD, the examiner noted that the Veteran was not exposed to a traumatic event, a traumatic event was not persistently reexperienced, there was no persistent avoidance of stimuli associated with the trauma, and there were no symptoms of increased arousal. The examiner opined that the Veteran's schizoaffective disorder was unrelated to military service and that her social functioning declined in 2004 after experiencing a serious beating. She also stated that there was no indication in the Veteran's claims file that she reported symptoms consistent with schizoaffective disorder during her military service, and that her psychiatric complaints during that time were noted to be related to interpersonal difficulties, did not reach a level consistent with a formal psychiatric disorder, and did not indicate any impairment of functioning, as her performance evaluations at that time showed excellent occupational functioning during service. The examiner did not find any evidence of record indicating that the Veteran's current diagnoses were evidenced prior to military service or during military service. Analysis After reviewing all the evidence of record, the Board finds that there is no current diagnosis of PTSD, and no evidence linking the Veteran's other current psychiatric diagnoses to any event in active duty service. The Veteran currently has a number of psychiatric diagnoses from a variety of sources, some of which conflict in their findings. When evaluating medical opinions it is the province of the Board to weigh the evidence and decide where to give credit and where to withhold the same, and in so doing, to also accept certain medical opinions over others. See Evans v. West, 12 Vet. App. 22, 30 (1999); Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board cannot make its own independent medical determinations, and there must be plausible reasons for favoring one opinion over another. See also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444 (2000). An evaluation of the probative value of a medical opinion or diagnosis is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusions reached. The Board may then determine the credibility and weight to be attached to such opinions. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). While the Veteran has been given diagnoses of PTSD, these diagnoses are not supported with any evidence that the diagnosing medical professionals used the criteria required by the DSM-IV when assigning the Veteran a diagnosis of PTSD, as there is no discussion of her specific stressors or the qualifying symptomatic criteria, or that they were specifically considering the Veteran's military sexual harassment, and not other post-service traumas, as potential stressors. See 38 C.F.R. § 4.125(a). The Veteran was first diagnosed with PTSD by a VA psychiatrist in December 2004, but this was immediately following her violent assault in October 2004, and the record indicates that this event was her primary stressor. The VA treating psychiatrist made no indication of whether a PTSD diagnosis at that time could have been supported by the events experienced by the Veteran in service. The examinations provided by the January 2013 and June 2013 VA examiners which found that the Veteran did not meet the criteria for a diagnosis of PTSD and included findings on all DSM-IV required criteria, therefore have far greater probative value. Additionally, the Veteran's private psychiatrist also provided a February 2010 evaluation which diagnosed the Veteran with chronic PTSD, but he also indicated that this was following the traumatic experience of being raped twice in the military. The Veteran has never contended to VA that she was raped in the service, nor is there any evidence of record that this occurred. As a medical opinion can be no better than the facts alleged by the Veteran, an opinion based on an inaccurate factual premise has limited, if any, probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005); Swann v. Brown, 5 Vet. App. 229, 233 (1993). The Board therefore finds no probative value in the private psychiatrist's opinion, as it is based on an inaccurate factual premise. The Board also notes that the Veteran's VA records include diagnoses of PTSD "by history." The Board emphasizes that such notations in the Veteran's VA treatment records do not constitute valid diagnoses of PTSD, as, again, such a diagnosis must be in accordance with the criteria of the DSM-IV. 38 C.F.R. § 4.125(a). References to PTSD "by history" are also not current diagnoses, but are taken from prior records or self-reported medical history. These medical records therefore provide no probative value in deciding the current claim. The appellant also has other valid psychiatric diagnoses provided by competent medical professionals, including schizoaffective disorder, depressive disorder, dysthymic disorder, anxiety disorder, bipolar disorder, and adjustment disorder, but these disorders are not shown by any competent medical evidence to be related to her service. Without competent and probative evidence indicating that the Veteran's psychiatric disorders were caused by or otherwise related to an injury during service, service connection is not warranted. While the Veteran's service treatment records show that she did report mental health complaints during service, these incidents have not been connected by a competent medical professional to her current psychiatric disorders. The Veteran has reported having nightmares related to being attacked or threatened by men, and while she has recounted several upsetting incidents of sexual harassment in service, the Veteran's records also show that she has had a long history of partner abuse and was seriously assaulted and injured in an attack in October 2004, which VA examiners have indicated is the more likely source of her current distress. The Veteran's private and VA treating medical professionals have not provided any opinion evidence regarding whether the Veteran's psychiatric disorders were caused by or incurred in service. The only opinions to discuss this relationship, those within the January and June 2013 VA examination reports, clearly state that the Veteran's current psychiatric problems were not caused by or otherwise etiologically related to her military service. Thus, the overwhelming preponderance of the medical evidence is against finding that the Veteran has a psychiatric disorder that is connected to service. The Veteran, as a layperson, is competent to report on matters observed or within her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board acknowledges that the appellant is competent to make statements regarding the stress of being sexually harassed and threatened during service. She is also competent to report symptoms such as nightmares or feeling anxiety. However, a probative medical opinion on the etiology or underlying causes of a psychiatric disorder requires the specialized training of a medical professional. In this case, as a layperson not shown to possess appropriate medical training and expertise, the appellant is not competent to render a persuasive or competent medical opinion on whether her currently diagnosed psychiatric disorders were caused by or otherwise related to her military service. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir 2006) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Hence, her assertions in this regard do not constitute competent and persuasive evidence in support of the claim for service connection. The Board also notes that while the January 2013 VA examiner noted that the Veteran's personality disorder predated her service. A personality disorder, whenever manifested is not subject to service connection. 38 C.F.R. § 3.303(c). There is no evidence of record which supports a finding that the Veteran's currently diagnosed acquired psychiatric disorders existed before or during service. While "nervous trouble" and "nervous stomach" were noted on the Veteran's entrance examination, this in no way constitutes a psychiatric diagnosis clearly indicative of a psychiatric condition existing at that time. The evidence of record only shows that the Veteran was first diagnosed with anxiety in July 1989 and with depression in July 1992. No acquired psychiatric disorder was shown during service nor is one shown to be related to service. The Board has considered whether service connection for a psychiatric disorder, such as psychosis, is warranted on a presumptive basis. A February 2011 SSA evaluation diagnosed the Veteran with bipolar disorder with psychotic features vs. psychotic disorder; however, the vast majority of the Veteran's psychiatric assessments and diagnoses do not indicate that she has any type of psychosis, nor has the Veteran asserted that she has had such a condition at any time. There is also absolutely no evidence of a psychosis or other similar psychiatric disorder manifesting to a compensably disabling degree within one year of her discharge from active duty service. Therefore service connection on a presumptive basis as a chronic disease is also not warranted. See 38 C.F.R. §§ 3.307, 3.309, 3.384. In short, the preponderance of the evidence indicates that the Veteran does meet the diagnostic criteria for a diagnosis of PTSD, and there is no competent and probative evidence showing that any of her current psychiatric disabilities had their onset during or are otherwise related to her active service, either directly or presumptively. Accordingly, the preponderance of the evidence is against the claim for service connection. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for an acquired psychiatric disability, to include PTSD due to military sexual trauma, is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs