Citation Nr: 1338541 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 09-47 927 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a chronic acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), major depression, schizotypal personality disorder, borderline personality disorder, polysubstance abuse, bipolar disorder, impulse control disorder, and pedophilia. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD A.E.H. Gibson, Associate Counsel INTRODUCTION The Veteran served on active duty from June to December 1987. This appeal to the Board of Veterans' Appeals (Board/BVA) is from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2011 and May 2013, the Board remanded this claim to the RO via the Appeals Management Center (AMC), each time to have the Veteran undergo a VA compensation examination to try to reconcile his several psychiatric diagnoses and to determine the likelihood that any of these diagnoses are indication of disability superimposed upon the schizotypal personality disorder diagnosed during his relatively brief period of active duty military service or, instead, more likely the result of other factors unrelated to his military service. He had the VA examination in August 2011, and clarifying addenda were drafted by the same examiner in January and October 2012; however, these reports, even read in conjunction with one another, were insufficient for adjudicatory purposes because the examiner did not address all diagnoses. So, in August 2013, the Board requested an expert medical opinion from the Veterans Health Administration (VHA opinion). This additional opinion was received in September 2013, and a copy was forwarded to the Veteran and his representative on September 17, 2013. They were given 60 days from the date of the letter to submit additional evidence or argument in response to the opinion, and notified that if nothing was received in that time period, the Board would proceed to adjudicating the appeal based on the existing evidence of record. On September 23, 2013, the Veteran indicated he had no further evidence to submit and, therefore, wanted the Board to immediately proceed with adjudication of his claim. FINDING OF FACT The preponderance of the evidence weighs against finding that any of the Veteran's diagnoses (PTSD, major depression, schizotypal personality disorder, borderline personality disorder, polysubstance abuse, bipolar disorder, impulse control disorder, and pedophilia) incepted or were aggravated by his service, and none are related to his service in any way. CONCLUSION OF LAW His PTSD, major depression, schizotypal personality disorder, borderline personality disorder, polysubstance abuse, bipolar disorder, impulse control disorder, and pedophilia were not caused by, incurred in, or aggravated by his service, may not be presumed to have been incurred during his service, and are not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1133, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 4.9, 4.127 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claim Assistance Act (VCAA) The VCAA provides that VA has duties to notify and assist a claimant in substantiating a claim 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) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative of the evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist him in obtaining; and, (3) that he is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2013). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran was provided this required notice in November 2007, prior to the initial adjudication of his claim by the RO, so in the preferred sequence. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). He has not alleged any deficiency in the notice, certainly none that will affect the essential fairness of the adjudication of his claim and outcome of his appeal so as to, in turn, be considered unduly prejudicial. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The VCAA further provides that VA has a duty to assist in the development of a claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2013). This duty includes assistance in obtaining relevant records, including service treatment records (STRs) and other pertinent medical records, as well as the provision of an examination when necessary to make a decision on the claim. Id. This duty to assist in the development of this claim has been satisfied. The Veteran's STRs and post-service VA and private medical records have been obtained and associated with the claims file for consideration. He has not identified any other outstanding records that he wanted VA to obtain or that he believed were relevant to this claim that have not been obtained, except for treatment records from Poplar Bluff Regional Medical Center and Bootheel Counseling Services. In regards to Poplar Bluff, the RO sent requests in January and April 2008, but with no response. The Veteran was notified that these records were never received in the June 2008 rating decision and the October 2009 statement of the case (SOC), and he was advised in an April 2008 letter that he was ultimately responsible for providing copies of these records. 38 C.F.R. § 3.159(c) and (e). To date, he has not submitted copies of these records. In regards to Bootheel, a response to the RO's request was received in February 2008, indicating this facility had none of the Veteran's records for the time period requested, from 2007 onwards. Copies of records from 2003 and 2004 were received and associated with the claim file for consideration. The Veteran has not supplemented the record with any additional records from Bootheel Counseling services. The Veteran also was provided a VA compensation examination in July 2011, but the examiner did not address whether any psychiatric diagnoses were related to service. The Board then remanded the claim, including in May 2012, to try and obtain the supplemental comment needed, but also ultimately to no real avail. Therefore, eventually, because of the complexity of the issues involved in this case, the Board requested a VHA expert medical opinion. A psychiatrist reviewed the Veteran's file and records, which resulted in a negative medical nexus opinion regarding the likelihood his psychiatric disorders are related or attributable to his service. This opinion is adequate to adjudicate the claim on its underlying merits, as the commenting psychiatrist clearly did a thorough review of the evidence, including considering the Veteran's contentions and recounted history, prior to rendering the opinion that is supported with explanatory rationale, which is where most of the probative value of an opinion is derived. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran was provided a copy of the VHA opinion and given an opportunity to respond to it. 38 C.F.R. § 20.903. He did not have any response, but instead asked the Board to immediately adjudicate his claim. Thus, as there is no indication or allegation that any other relevant evidence remains outstanding, which is obtainable, the Board finds that the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002). Standard of Review In deciding this claim, the Board has reviewed all of the evidence in the claim file, both the physical claim file and electronic ("Virtual VA") file, and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). But while the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See Gonzales, 218 F.3d at 1380-81. The Board's analysis, therefore, focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, concerning the claim. The Veteran must not assume the Board has overlooked pieces of evidence that are not explicitly discussed. The law requires only that the Board address its reasons for rejecting evidence favorable to him. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, so including both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, meaning about evenly balanced for and against it, with the Veteran prevailing in either event, or whether instead the preponderance of the evidence is against the claim, in which case it is denied. Id. The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine whether the evidence also is "credible," or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must additionally determine whether it is also credible). Only if the evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The third and final step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has personal knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (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 professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation," such as varicose veins, tinnitus, flat feet, or a dislocated shoulder. See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398 (1995). On the other hand, laypersons may not be competent in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). Competent medical, as opposed to lay, evidence is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). In determining probative value, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997). In ultimately rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board is required to consider all potential bases of entitlement. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). VA has a duty to address all arguments put forth by a claimant and/or theories under which entitlement to benefits sought may be awarded. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Buckley v. West, 12 Vet. App. 76, 83 (1998). Governing Statutes, Regulations and Cases The Veteran was administratively discharged from active duty service in December 1987 due to the diagnosis of schizotypal personality disorder, which was not detected and noted on his entrance examination. Since separation from service, he has been diagnosed additionally with PTSD, major depression, borderline personality disorder, polysubstance abuse, bipolar disorder, impulse control disorder, and pedophilia. He believes all of these diagnoses are attributable to his military service. Service connection is granted for current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). Establishing entitlement to service connection on a direct-incurrence basis requires competent and credible evidence showing: (1) the existence of a present disability or, at the very least, showing the Veteran has had the alleged disability at some point since the filing of his claim; (2) in-service incurrence or aggravation of a relevant disease or an injury; and, (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for psychoses can be established under specific circumstances by way of presumption. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Here, the evidence does not show and the Veteran does not contend that he has psychoses, at least according to 38 C.F.R. § 3.384. This VA regulation indicates "psychoses" include the following specific disorders: brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. For purposes of establishing service connection, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C.A. §§ 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). If a condition is not noted upon entrance into service, then to rebut the presumption of soundness at service entrance VA must show by clear and unmistakable evidence both that there was a pre-existing condition and that it was not aggravated during or by the Veteran's service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). "Clear and unmistakable evidence" is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999). It is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003) citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b) (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Medical evidence is generally, although, as mentioned, not always, required to associate the claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 11 Vet. App. 148, 158 (1998); and McQueen v. West, 13 Vet. App. 237 (1999). In addition to the above, establishing entitlement to service connection for PTSD in particular requires having: (1) medical evidence diagnosing this condition in accordance with 38 C.F.R. § 4.125(a), which requires the condition be diagnosed in accordance with the Fourth Edition of the Diagnostic and Statistic Manual of Mental Disorders (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 DSM-V (the latest version of the DSM) has been officially released. However, 38 C.F.R. § 4.130 still explicitly refers to the DSM-IV. The regulation legally requires to continue considering this prior version of the DSM until such time as the regulation is changed. There is a regulation change in the works that would change the regulation to reference "the current version of the DSM." But it is unclear when that proposed change will be published. The Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) essentially agreed that their target for moving to DSM-V was October 1, coinciding with the beginning of the new fiscal year. But, for now, the regulation still explicitly refers to the DSM-IV, regardless of the fact that one may begin seeing private evidence referring to criteria under the DSM-V. Generally speaking, service connection cannot be established for personality disorders because they are "defects," which are not "diseases" or "injuries" within the meaning of applicable legislation for VA disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9, 4.127 (2013). Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90 (July 18, 1990). Congenital or developmental "defects," such as a personality disorders, automatically rebut the presumption of soundness and therefore are considered to have preexisted service. 38 C.F.R. §§ 3.303(c), 4.9; Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); Winn v. Brown, 8 Vet. App. 510, 516 (1996). As such, "[s]ervice connection of personality disorders, whether on a direct basis or by aggravation, is...prohibited...." 61 Fed. Reg. 52,695. However, 38 C.F.R. § 4.127 provides that disability resulting from a mental disorder that is superimposed upon a personality disorder may be service connected, and, in accordance with 38 C.F.R. § 3.310(a), personality disorders that result from service connected disabilities may be service connected on a secondary basis. VAOPGCPREC 82-90 (July 18, 1990); 61 Fed. Reg. 52,695. Turning to the evidence, at the Veteran's enlistment examination in May 1986, his psychiatric assessment was "normal." He entered active duty service in June 1987. In November 1987, he was diagnosed with schizotypal personality disorder. The prognosis was determined to be poor, and it was found to be unrelated to service, but he was administratively discharged because of it. At his December 1987 separation examination, he was again psychiatrically assessed as "normal." In the years following separation from service, the Veteran was diagnosed additionally with PTSD, major depression, borderline personality disorder, polysubstance abuse, bipolar disorder, impulse control disorder, and pedophilia. He has claimed these diagnoses, along with his schizotypal personality disorder, are related to his service, and that he was never bothered by or diagnosed with any mental health disorder prior to his service. He also argues that active duty service aggravated his personality disorder. A VA compensation examination was scheduled to investigate the Veteran's theories of entitlement to benefits. During the July 2011 VA examination, he was diagnosed with major depressive disorder, cocaine dependence, opioid dependence, and cannabis abuse, but an opinion was not provided on the etiologies of these, or any of his other, diagnoses. That VA examiner re-addressed the Veteran's claim in August 2011, January 2012, and October 2012, each time opining that the major depressive disorder and borderline personality disorder were unrelated to his military service. That VA examiner observed the Veteran had a recurrent pattern of depressive episodes even prior to his service, and those symptoms were subsumed by the borderline personality diagnosis. The Veteran's use of substances was also consistent with borderline personality disorder, and were considered a factor in diagnosing borderline personality, but substance use and abuse was not caused by or related to service. The examiner conceded that military service may have exacerbated major depression and borderline personality while in service, but it was unlikely they had remained heightened after separation. So, in other words, even if there was temporary worsening during service of pre-existing disability, it was not chronic or permanent, which is required to conclude there was actual aggravation. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Nevertheless, that VA examiner did not provide opinions on the Veteran's other diagnoses, except for commenting in October 2012 that the Veteran did not meet the criteria for a pedophilia diagnosis. Although he had served ten years in jail for sodomy of a child, a pedophilia diagnosis requires a period of at least 6 months of recurrent, intense sexual fantasies, sexual urges, or behaviors involving prepubescent children, which the Veteran did not endorse. The VA examiner indicated he could not opine on the etiology of disorders that he did not diagnose in the initial July 2011 VA examination. Given the complexities of this case, and the VA examiner's reluctance to consider the additional diagnoses, the Board requested a VHA medical expert opinion. The September 2013 VHA opinion addressed each of the Veteran's diagnoses. The reviewing psychiatrist first addressed the issue of whether the Veteran entered service with a pre-existing psychiatric disorder. She commented that the examinations provided prior to entrance into active duty are relatively crude in screening mental illness, and are not designed to pick up complex psychopathology, which she opined the Veteran had upon entrance to service due to a traumatic and toxic childhood and as a result of genetic contributions. His father and several of his aunts and uncles had significant alcohol problems, an aunt had bipolar disorder, and two cousins had mental illness. She noted that his December 1987 discharge examination showed a "normal" clinical psychiatric evaluation despite being diagnosed with schizotypal personality disorder just a month earlier, in November 1987. She opined that the Veteran's in-service schizotypal personality diagnosis was not entirely accurate, however, she did agree that he had a personality disorder. She explained that schizotypal personality disorder causes excessive social anxiety that does not diminish with familiarity, and that those with it exhibit odd and peculiar behavior, which she did not see in any of his treatment records. She noted that no other treatment provider ever diagnosed him with schizotypal personality. As an example, in a 1990 psychological evaluation, he was reported to have been "sociable with others and charming toward women" on the ward, which is the opposite of how a schizotypal personality would act. On the contrary, she indicated this type of behavior is commonly seen in those with borderline, narcissistic, and antisocial personality disorders. As further example, she noted that he bragged about his sexual conquests and how he enjoyed pursuing women, only to lose interest once attaining his goal, which is not the psychopathology of a schizotypal personality. Rather than schizotypal personality disorder, she thought a combination of borderline personality disorder and bipolar disorder, which had been diagnosed by several different clinicians, would have been a more accurate diagnosis. She noted that he was reported to exhibit mood swings, and explained that borderline personality disorder can present with symptoms that are very similar to bipolar disorder, with similar levels of emotional dyscontrol and impulsivity and cognitive distortions. Although the symptoms are very similar, borderline personality disorder symptoms result from ego deficits that were created in childhood, as opposed to bipolar symptoms that result from a biological process. She opined that he has both borderline personality and bipolar disorders, which is the reason he requires combined treatment of a therapeutic environment, to support his ego deficits, and psychiatric medications, to stabilize his mood. She indicated that extensive medical documentation shows clearly and unmistakably that the Veteran's polysubstance abuse began very early in childhood, and was pre-existing service. He reportedly began using heavy alcohol at the age of 9, marijuana by age 11, daily use of marijuana by age 13 - which created paranoia - and cocaine and LSD by age 14. His brain was still developing at these ages. Further, extensive medical documentation shows a history of extensive sexual trauma during his childhood, from ages 4 to 14 years old. She noted that the military did not have access to this information. She also indicated that his history of substance abuse and sexual trauma would have had a significantly greater impact on his brain development and subsequent mental health than six months of routine military service. She supported this conclusion with reference to records that diagnosed PTSD on the basis of early childhood sexual abuse by a cousin. She said that it was questionable whether his symptoms meet the criteria under the DSM-IV for a PTSD diagnosis, but that it was reasonable to conclude based on the available evidence that he was in the process of developing psychopathology from early childhood trauma at the time of his entrance into military service. She supported her conclusion with reference to records that show the Veteran reporting suicidal ideation since the age of 9 or 10, and that he reported having attempted suicide because he was raped from the ages of 4 through 16 and "just can't forget about it." Additional records document his reports of perpetrating sexual abuse on children three or four years younger than him prior to service, which is highly indicative of serious psychopathology. She said the records did not provide enough evidence to show whether he met the criteria for pedophilia. She agreed it would be suspected from someone who served ten years in jail for having sex with a minor, but in 2004 he denied having fantasies or feeling excitement for children. She said that impulse control was diagnosed by some clinicians to explain some of the same behaviors that led to his bipolar disorder diagnosis, and she did not see these two disorder as separate diagnoses. She also said that his diagnosed major depression disorder was redundant when also diagnosed with bipolar disorder, and that he clearly had bipolar rather than major depression, as he exhibited symptoms consistent with mania that are not seen in patients with only major depression. In sum, she reiterated that the medical evidence of record showed the presence of psychopathology when he entered service, and that his in-service diagnosis of schizotypal personality was actually borderline personality disorder, with features of PTSD influenced by early childhood sexual trauma and polysubstance abuse, and a genetic predisposition. She reiterated that the evidence shows he had already had chronic suicidal thoughts and depression associated with his own early childhood sexual abuse, and that he had already perpetrated sexual abuse on children by the time he entered the military. She reiterated that bipolar disorder symptoms are difficult to distinguish from borderline personality symptoms, due to similar levels of emotional dyscontrol, impulsivity, and cognitive distortion. She said that bipolar disorder is biologically based and noted the Veteran has a genetic predisposition for it. She said that there is no indication of the presence of any symptoms during service that he did not have prior to service, and no evidence at all to indicate that any of his symptoms in service increased during service beyond their natural progression. She said after reviewing records of treatment after separation that she could find no evidence of him mentioning any incident or problems in service, aside from being discharged due to underage drinking. She said that is clear and unmistakable that his bipolar disorder and his PTSD symptoms were superimposed upon his borderline personality disorder when he began service, and that they were not aggravated by his service. Modern medical research has shown that early and extensive drug abuse and sexual abuse has a significant impact on brain development and subsequent mental health. She reiterated that he has an overwhelming number of documented reports of a history of both in his childhood, such that his reportedly routine, brief, stateside military service would "pale in comparison." Based on this collective body of evidence, the Board does not find that service connection is warranted. The Veteran's entrance examination did not note any psychiatric disabilities, and he was clinically evaluated as "normal." Thus, he at least initially will be considered to have been in sound mental health when entering service, requiring clear and unmistakable evidence to rebut this presumption and show he had a pre-existing psychiatric disability. However, because he was diagnosed with a personality disorder, the presumption of soundness is automatically rebutted. 38 C.F.R. § 3.303(c). Thus, his claim that his service aggravated his personality disorder is not probative, as service connection cannot be established on a direct basis or by aggravation for a personality disorder. 61 Fed. Reg. 52,695. But, as explained, a personality disorder can be service connected if it has resulted from a service-connected disability. He does not claim, and the evidence does not raise the possibility, that his personality disorders may have resulted from a service-connected disability, so entitlement to service connection on a secondary basis under 38 C.F.R. § 3.310 has not been raised by him or the evidence of record. Also, an acquired psychiatric disability that is superimposed upon a personality disorder can be service connected - if it is distinct from the personality disorder but related to service. Again, because no psychiatric abnormality was found during his May 1986 pre-enlistment examination, he is presumed to have been in sound mental health when entering service, at least in regards to acquired psychiatric disabilities, unless clear and unmistakable evidence shows there was a pre-existing condition that was not aggravated by his service or, if worsened, was not beyond the condition's natural progression. The VHA medical expert opinion surmised that he had entered service after enduring a traumatic childhood involving extensive sexual abuse and substance abuse, which in turn had had a negative impact on his brain development and mental health. The VHA psychiatrist indicated that it was clear and unmistakable from her review of the records that he had entered service with bipolar disorder, which he had a genetic predisposition for, and PTSD features superimposed upon his personality disorder, which she indicated was more likely borderline personality rather than schizotypal personality. She said that the trauma he reportedly had, as well as a genetic predisposition, led to his bipolar disorder and PTSD symptoms, but most importantly that it had occurred prior to, not during, his military service. She attributed his PTSD symptoms-she could not determine whether he met the criteria for a PTSD diagnosis pursuant to the DSM-IV due to a lack of evidence-on repeated rapes during his childhood. She also pointed that, prior to service, he had perpetrated sexual abuse on children, indicating serious psychopathology before enlistment. She also opined that bipolar disorder and his PTSD symptoms were not aggravated by his service, at least in the sense of being chronically or permanently worsened, partly owing to his relatively brief time in service (just from June to December 1987) and the absence of any inciting event during his service. She said that his experiences in service, which was brief and stateside only, pale in comparison to his childhood experiences, so were far less traumatic and far less likely to result in chronic mental illness. She did not find any symptoms during his service that were not present before service, and she found nothing suggesting that any of his symptoms had increased in severity during his service over and beyond their normal progression. She commented that his extensive post-service treatment records do not record any complaints or problems regarding his service, and instead refer consistently to incidents in his childhood, so before his service. In regards to the major depressive disorder and impulse control disorder, this VHA psychiatrist opined that the major depressive disorder was subsumed by the Veteran's bipolar disorder diagnosis. She also indicated that impulse control disorder was usually diagnosed to explain some of the behaviors that led to his bipolar diagnosis, and similarly opined that the impulse control disorder was subsumed by the bipolar disorder. Since these symptoms are considered part and parcel of the bipolar disorder, they too are found to have been pre-existing service and not aggravated by service. Polysubstance abuse also pre-existed service, as it began in early childhood. No opinion has been provided as to whether the Veteran's substance abuse increased in severity during his service, however, one is not necessary. Service connection for polysubstance abuse is precluded, unless it is found to be secondary to a service connected disability. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Here, polysubstance abuse has not been related to service in any way. The Veteran has no other service-connected disabilities that it could arise secondarily from, or that could have aggravated it. 38 C.F.R. § 3.310(a) and (b). In regards to the pedophilia, both the VHA psychiatrist and the VA examiner opined that the Veteran did not meet the criteria for this diagnosis, despite his reported history of going to jail for having sex with a child. He denied having fantasies for children in 2004, and the evidence does not show he had a prolonged, 6-month period or more, of recurrent, intense sexual fantasies, sexual urges, or behaviors involving prepubescent children. The Veteran's statement that he entered service without ever having any psychiatric troubles, and that his service caused all of his psychiatric diagnoses is not probative. He is competent to describe his own feelings regarding his mental health, but he has not been shown to have the training or expertise to render a competent opinion as to the source of his psychopathology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). Indeed, his theory has been investigated by a medical expert, psychiatrist no less, who did not find any connection between any of his psychiatric symptoms and consequent disability and his military service. Jandreau, supra. Accordingly, the preponderance of the evidence is against this claim. In this circumstance, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER The claim of entitlement to service connection for an acquired psychiatric disorder, including PTSD, major depression, schizotypal personality disorder, borderline personality disorder, polysubstance abuse, bipolar disorder, impulse control disorder, and pedophilia, is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs