Citation Nr: 1343153 Decision Date: 12/27/13 Archive Date: 01/07/14 DOCKET NO. 08-11 000 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), major depressive disorder, gender identity disorder, and personality disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran had active service from September 1985 to August 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from decisions by the RO which denied the benefits sought on appeal. A hearing before the undersigned Acting Veterans Law Judge was held at the RO in April 2011. The Board promulgated a decision denying the benefit sought in September 2011. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). In March 2012, the Court vacated the Board decision and remanded the Veteran's claim for action consistent with the directives of a joint motion for remand (JMR). The JMR was premised on the failure of the Board to discuss the applicability of the presumption of soundness under 38 U.S.C.A. § 1111 to this case. The appeal was then remanded by the Board in May 2013 for further evidentiary development, including obtaining outstanding post-service VA treatment records, Social Security Administration (SSA) disability records, and obtaining a VA examination. This was accomplished, and the claim was readjudicated in an August 2013 supplemental statement of the case. For these reasons, the Board concludes that that the Board's remand orders have been substantially complied with, and it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). It is noted that the Veteran has officially changed her name, and is in the process of going through hormone replacement therapy in the effort to become a woman. Thus, while the Veteran was a man during service, the Board, out of deference to the Veteran's personal choice, will refer to her in the female voice throughout this decision. This appeal was processed using the Veterans Benefits Management System (VBMS). Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The Board has reviewed the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All evidence necessary for adjudication of the Veteran's claim has been obtained by VA. 2. A psychiatric disorder was not "noted" at service entrance. 3. The presumption of soundness does not apply as it is not shown that the Veteran's PTSD manifested during her service. 4. The Veteran is currently diagnosed with PTSD, major depressive disorder, gender identity disorder, and personality disorder. 5. In-service stressors, sufficient to support a diagnosis of PTSD, have been verified. 6. The Veteran's currently diagnosed PTSD, major depressive disorder, gender identity disorder, and personality disorder did not begin during her military service, and are not otherwise related to service, to include as a result of her verified in-service stressor; the evidence similarly fails to establish that an Axis I acquired psychiatric disability was aggravated during her military service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder, gender identity disorder, and personality disorder, have not been met. 38 U.S.C.A. §§ 1110, 1111, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. The record reflects the Veteran was provided VCAA notice in a letter mailed in October 2006. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show she had a current disability, a disease or injury in service, and evidence of a nexus between the post-service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. The letter also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. Moreover, the Board previously adjudicated the Veteran's claim, finding that the notice requirements had been satisfied, this claim was appealed to the Court, and eventually returned to the Board. However, neither the Veteran, nor any of her representatives, has either alleged, or demonstrated, at any time during the appeal of the Veteran's claim (including in the appeal to the Court) that she has been prejudiced in any way with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Thus, adjudication of his claim at this time is warranted. With respect to the duty to assist in this case, the Veteran's service treatment records, SSA records, and all VA and private medical records identified by her have been obtained and associated with the claims file. The Veteran testified at a hearing at the RO before the undersigned in April 2011. Further, and pursuant to the Board's May 2013 remand, the Veteran was afforded a VA examination in June 2013 to assist in determining the nature and etiology of all acquired psychiatric disorders. The Board finds the June 2013 VA medical opinion to be adequate as the examiner conducted an in-depth review of the claims file, and provided a detailed rationale for all opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). It is noted that the Veteran's representative voiced some objection to the adequacy of the June 2013 examination, however, as is discussed below, the Board ultimately finds that the opinion is adequate for rating purposes. Based on a review of the claims file, the Board finds that there is no indication that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may 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 acquired psychiatric disorders in this case, to include PTSD major depressive disorder, gender identity disorder, and personality disorder, are not considered to be psychoses (a "chronic disease" listed under 38 C.F.R. § 3.309(a)); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). To establish service connection for PTSD the evidence must satisfy three basic elements. There must be 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In July 2010 the regulations pertaining to service connection for PTSD were amended. Effective July 13, 2010, if a stressor claimed by a veteran is related to the veteran's "fear of hostile military or terrorist activity" and a VA or VA-contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor so long as there is not clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service. See Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39,843, 39,852 (July 13, 2010) (codified at 38 C.F.R. § 3.304(f)(3)) and 75 Fed. Reg. 41,092 (July 14, 2010) (correcting the effective date of the rule published on July 13, 2010). For purposes of this section, "fear of hostile military or terrorist activity" means that "a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, . . . , and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror." 38 C.F.R. § 3.304(f)(3). These revised regulations are applicable to the Veteran's claim. A veteran is presumed to be in sound condition upon entrance into service, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where evidence or medical judgment is such as to warrant a finding that the disease or injury existed before acceptance and enrollment. 38 U.S.C.A. §§ 1111, 1132. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). Where such defects, infirmities or disorders are not noted when examined, accepted, and enrolled for service, pursuant to 38 U.S.C.A. §§ 1111, 1132 and 38 C.F.R. § 3.304, in order to rebut the presumption of soundness on entry into service, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-03. The presumption of soundness is applied, if VA is unable to rebut the presumption, meaning the disease or injury that manifested in service is deemed incurred in service, such that the second element of service connection is established. At that point, however, a veteran still must establish that he has a current disability that is related to the in-service injury or disease. Here, the Veteran contends that she currently experiences symptoms of PTSD, including nightmares and flashbacks of various events that she photographed and from pictures that she processed while working as a still photographer in service. As such, she believes that her current psychiatric problems are related to her military service. The Veteran also asserted that she was placed on medical hold shortly after she entered service, and testified that not knowing whether she would be able to continue her military service caused her a great deal of stress. Initially, the Board must determine whether the presumption of soundness under 38 U.S.C.A. §§ 1111, 1132 applies in this case. The relevant evidence on this question includes a February 2007 VA examination report where the examiner opined that it was at least as likely as not that the Veteran suffered PTSD in her youth and that this was "possibly aggravated" by service. Although this evidence suggests that an acquired psychiatric disability, to include PTSD, pre-existed entrance into service, the Board finds that the presumption of soundness has not been rebutted by clear and unmistakable evidence that an acquired psychiatric disability existed prior to service as required under 38 U.S.C.A. §§ 1111, 1132. In this regard, the Board finds that the Veteran was found to be psychiatrically normal at a November 1984 physical examination prior to entrance into service. Further, although the Veteran has acknowledged that she had a childhood history of abuse, she has also stated that she did not have psychiatric problems upon entry into service. On a medical history survey completed in conjunction with her enlistment physical, the Veteran denied any history of nervous trouble, frequent trouble sleeping, or depression. Additionally, in the most recent June 2013 VA examination report, conducted pursuant to the Board's May 2013 remand, the VA examiner acknowledged that there was no pre-service medical documentation suggesting that the Veteran's PTSD had its onset prior to service, and thus concluded that the Veteran's PTSD did not pre-exist service. However, as noted, the presumption of soundness applies only where there is evidence that a disease or injury was not noted upon entry into service manifested or was incurred in service. See Gilbert v. Shinseki, 26 Vet. App. 48, 54 (2012). The Court has cautioned that the presumption of soundness is not a sword for a veteran to fulfill the second element of service connection without any evidence of the manifestation of an in-service disability. Id. Otherwise stated, before the presumption of soundness is for application, there must be evidence that a disease or injury that was not noted upon entry to service manifested or was incurred in service. See Holton v. Shinseki, 557 F.3d 1362, 1367 (Fed. Cir. 2009) (the presumption of soundness does not "relieve the veteran of the burden of showing that [he] suffered from a disease or injury while in service"); Horn v. Shinseki, 25 Vet. App. 231, 236 (2012) ("In order to invoke the presumption of soundness, a claimant must show that he or she suffered from a disease or injury while in service."). Here, the evidence does not show that the Veteran's currently diagnosed PTSD manifested during service. As the examiner in June 2013 explained, the service treatment records did not show the diagnosis of any psychiatric disability. The examiner noted that the Veteran was referred for a mental health consultation in June 1990 to evaluate the Veteran's extreme gullibility and low self-esteem. Specifically in June 1990, just two months before separation, the Veteran was evaluated by the chief of the mental health clinic. However, no Axis I psychiatric disability was diagnosed following that evaluation. As such, there is no showing that the Veteran had an Axis I psychiatric disability during service. To the extent that the Veteran has alleged that she did experience psychiatric problems during service, the Board finds that she lacks the medical training and expertise to provide a complex medical opinion as to the etiology of a psychiatric disability. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Moreover, the medical officer evaluated the Veteran during service, but found that her reported symptoms did not warrant the diagnosis of an Axis I psychiatric disability. As was explained, absent the predicate finding that a pre-service disease or injury manifested or was incurred in service, the presumption of soundness is not for application. See Gilbert, supra. Of note, in Gilbert, as here, the Veteran was diagnosed with an acquired psychiatric disability post-service, but the diagnosis was not rendered during service and there was no indication that the disability onset or was present during service. In Gilbert, the Veteran complained of several incidents in service which he believed caused his psychiatric disability. However, the Court explained that in such a circumstance, the presumption of soundness did not attach. As such, even though the Veteran has since service identified several in-service stressors which could support a PTSD diagnosis, the evidence does not show an in-service manifestation of any Axis I psychiatric disability. Therefore, the presumption of soundness is not for application. The analysis does not stop here, as it must now be determined whether the evidence of record makes it at least as likely as not that the Veteran's PTSD was either caused or aggravated by her military service. The occurrence of the Veteran's in-service stressor events are adequately verified in the record, as her personnel records reflect that she photographically documented an aircraft accident, and a statement from a fellow service photographer, corroborates that she was responsible for documenting plane crashes, child abuse incidents, and spousal abuse incidents, as well as an occasion when a flight-line airman was killed when a landing gear tire exploded. Therefore, the Board finds that the Veteran had these experiences during service. Moreover, a VA examiner in June 2013 acknowledged that the Veteran's photographing of horrific and traumatic sights in the military was adequate to support a diagnosis of PTSD. However, the question still remains whether the Veteran's currently diagnosed PTSD is the result of an in-service stressor. Weighing against the Veteran's claim are service treatment records which are absent for any diagnosis for PTSD. Although the Veteran has pointed to a number of outbursts and problems in service as evidence of the onset of an acquired psychiatric disability, the medical evidence of record from service does not actually show that any psychiatric disorder was ever diagnosed despite the fact that these behavioral problems were well-known. The record shows that the Veteran was first evaluated by the Chaplin/Family Advocacy Officer at a mental health services clinic in December 1985; however, the mental status examination was within normal limits, and the medical officer indicated that no diagnosis was warranted. Subsequent entries in January and March 1986, showed that the Veteran's records were screened for reassignment by mental health services, but again there was no indication of any mental health problems, and that she was again found to be medically eligible for retention in March 1986. Other than a single entry in June 1990, shortly before her discharge from service, the service treatment records showed no complaints, abnormalities or diagnosis for any psychiatric problems during service. Regarding the June 1990 entry, the service records show that the Veteran was seen by psychiatric services for stress. No specific findings were reported and no Axis I diagnosis was found to be warranted. Further, service records reveal that the Veteran was AWOL on the day that she was seen at the mental health clinic in June 1990, and subsequently received nonjudicial punishment (Article 15) for her actions, which included punching a hole in a wall. The records show that the Veteran was given a general discharge from service in August 1990, based on a pattern of misconduct during service that, in addition to her Article 15, included dereliction of duty, writing a bad check, and failing a dormitory inspection. A review of her Airman Performance Reports showed that in her first year of service (September 1985 to September 1986), the Veteran received an overall rating of 7 by her supervisor (on a scale of zero to nine). The evaluation report indicated that the Veteran had progressed at a slow but satisfactory rate, that she needed constant supervision, and that she lacked the ability to grasp both the practical and technical aspects of her job. The Veteran was not recommended for promotion to E-3 by her commanding officer in December 1986, based on her supervisor's recommendation that she was not progressing in a satisfactory manner and did not pay attention to detail. The Veteran's next two annual performance evaluations (1986 to 1987 and 1987 to 1988) showed marked improvement in her duty performance and attitude, and she was given an overall score on nine on both reports. However, her evaluations from September 1988 to September 1989, and September 1989 to March 1990, showed that her quality of work steadily deteriorated and was inconsistent and unpredictable. She was counseled numerous times on the condition of her dormitory room, her personal hygiene and the condition of her uniform with little or no improvement. She had angry outbursts at work and in the dormitory which alienated the Veteran from her peers, and despite financial counseling regarding several overdue accounts at various local businesses, she continue to spend to excess. The Veteran was not recommended for promotion to sergeant in October 1989, but was subsequently recommended and promoted to E-5 in February 1990. However, in July 1990, the Veteran's commanding officer recommended that the Veteran's appointment (promotion) be vacated. In a letter to her senior rating supervisor (Command Sergeant Major) dated in July 1990, the Veteran wrote that she realized that she had not performed as well as she could have aver the previous six months because of serious financial and personal problems, but she believed that she had finally straightened things out and wanted to continue her military service. On a Report of Medical History for separation from service in July 1990, the Veteran specifically denied any history of trouble sleeping, depression or excess worry, memory problems or nervous trouble of any sort, and no pertinent psychiatric abnormalities were found on examination at that time. As described, the evidence does not show that the Veteran's PTSD was diagnosed either during her military service or for many years thereafter. The Veteran even acknowledged in her testimony that she did not have any psychiatric problems during service and she denied seeking any psychiatric treatment or reporting any psychiatric problems during her service, including at the time of discharge from service. Moreover, no psychiatric disorder was diagnosed at the time of discharge from service. These pieces of evidence weigh heavily against a finding that the Veteran's later diagnosed PTSD was incurred in or is otherwise related to her military service. Further, in the June 2013 VA examination report, the examiner found that while the Veteran did have a repeated pattern of misconduct during service, it was a result of her personality disorder, and not PTSD. The Board finds the June 2013 VA medical opinion to be highly probative as the examiner conducted an in-depth review of the claims file, and provided a detailed rationale for all opinions rendered. See Prejean, 13 Vet. App. at 448-9. For these reasons, the Board finds that PTSD was not incurred in service and was not evidenced by the numerous outbursts and problems in service. Also weighing against a finding of a link between the currently diagnosed PTSD and the in-service stressor events are the post-service treatment records. Review of the VBMS record reveals that the Veteran first initiated contact with a mental health professional in June 2002 at which time the Veteran related that she had been depressed since February 2002 when she left her wife to be involved in an "alternative lifestyle consisting of bondage and sadomasochism." She also went into detail about abuse suffered as a child. She did not follow-up on treatment until May 2005 when she was psychiatrically hospitalized at the Tucson VA due to depression with suicidal ideation including a plan to jump off a bridge or walk into the desert and never return. She was diagnosed with major depressive disorder and the focus of treatment was primarily due to the Veteran's ex-wife. In a November 2006 VA outpatient clinic note, the Veteran reported nightmares about children being beaten and her father harming her sister. She also reported the death of her fiancé in 1997 as very upsetting. She did mention in-service photos of women and children who were beaten, raped, and included a 4-year-old boy with bloody electrical cord marks across his back and chest. At that time, she was having problems with sleep, concentration, depression, dreams, and anger. Subsequently, in December 2006, the Veteran was diagnosed with PTSD and dysthymic disorder. The Veteran continued to seek VA psychiatric treatment approximately once per month, the focus of which was predominantly related to childhood abuse. The Veteran was also afforded a VA examination in February 2007 to assist in determining the nature and etiology of her psychiatric disorders. Upon review of the claims file and mental status examination, the examiner diagnosed PTSD from childhood abuse, possibly aggravated by military service. However, the use of "possibly" renders the opinion too equivocal to provide the requisite nexus. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). Pursuant to the Board's May 2013 remand, the Veteran was afforded a second VA examination in June 2013 to investigate whether the verified in-service stressors caused or aggravated her currently diagnosed PTSD. As noted, the examiner acknowledged that the Veteran's verified in-service stressors could support a diagnosis of PTSD. However, she found that that in the case of this particular Veteran, the events she experienced in the military, although upsetting and stressful, did not appear to be medically sufficient to cause all or part of her particular syndrome of PTSD. The examiner observed that as had been stated by both the Veteran and her treatment providers, the Veteran's PTSD and its expressed symptoms primarily pertained to her severe childhood abuse. Moreover, the examiner found that the content of the Veteran's re-experiencing symptoms was predominately related to childhood traumas, and there were no avoidance or hyperarousal symptoms described in treatment notes or other documentation that would be relatable to these traumatic events in the military. In addition, the majority of treatment notes in the electronic medical record pertain to the Veteran's childhood abuse. The examiner also observed that more recently, the Veteran had discussed the 1997 car accident in which her fiancé died. In recent treatment, she cited this as the most traumatic event experienced. She also discontinued treatment because discussing this event was triggering memories and anxiety about childhood abuse. Notably, the examiner explained that the Veteran had not met Criteria "B" under the DSM-IV PTSD criteria (i.e., symptoms of reexperiencing) because her symptoms were predominately related to childhood traumas. Similarly, the record did not reflect documentation of symptoms supporting Criteria "C" and "D" under the DSM-IV (symptoms of avoidance and hyperarousal) which were relatable to the Veteran's in-service stressor events. Based on these reasons, the June 2013 VA examiner opined that the Veteran's childhood abuse and her fiancée's death in 1997, and not the in-service events, were the contributing stressors to the Veteran's PTSD diagnosis. The examiner further opined that currently diagnosed PTSD was less likely than not incurred in or caused by the claimed in-service stressors. As previously noted, the Board finds that June 2013 VA medical opinion to be highly probative on the question of a possible nexus to service. The Board also requested the examiner to consider whether the Veteran's repeated misconduct during service was indicative of the onset of her PTSD. The examiner reviewed the records showing that the Veteran had a repeated pattern of misconduct during military service, but suggested that it was a result of her previously diagnosed personality disorder and was not associated with her diagnosis of PTSD. The examiner noted that the Veteran's service treatment records did not show any psychiatric disorder having been diagnosed or any mention of symptoms of anxiety or depression as a result of her stressful experiences as a photographer, and there was nothing to associate her misconduct with the photography. Moreover, the examiner noted that the Veteran's performance difficulties were occurring as early as 1986, not long after she entered the military. In September 2013, the Veteran's representative argued that the VA examiner had erred by stating that the records do not demonstrate a military stressor that would account for the majority of the symptoms presentation, or that this constituted the bulk of treatment focus, in that the examiner appeared to conclude that it was an all or nothing debate. The representative suggested that under the liberal at least as likely as not standard there is no need to demonstrate that a "bulk" of the problem, or a "majority" of the treatment focused only on the service stressors. The representative acknowledged that the Veteran had readily stated that her childhood trauma was aggravated by the military stressors, and suggested that the VA examiner had failed to discuss the aspect of the conceded trauma dealing with the documentation of child abuse victims during service, and whether this one aspect of the military stressor more than any other could have brought the childhood traumas back up for the Veteran, and even now be hidden amongst the discussion of her own childhood traumas. The Board has considered this argument, and concurs that an in-service stressor need not be the predominant (that is bulk or majority) cause of PTSD. Moreover, if the portion of the examination report cited by the representative were to be read in isolation, it might appear to leave open the possibility that the Veteran's PTSD could have been aggravated by her in-service experiences. However, when the opinion is read in its entirety, the VA examiner's opinion is very clear that she does not believe that the Veteran's corroborated in-service stressors caused or aggravated her PTSD. Although the examiner found that the witnessing of a traumatic event, such as the ones experienced by the Veteran during service, would be sufficient to establish Criteria "A" under the DSM-IV for PTSD, the examiner explained that in the Veteran's case the evidence did not demonstrate that the Veteran met Criteria B, C, or D under the DSM-IV for PTSD as a result of the in-service experiences. The examiner explained that the symptoms of reexperiencing, avoidance, and hyperarousal that the Veteran experienced, and which formed the basis of her PTSD diagnosis, were associated with childhood abuse and not with the Veteran's experiences in service. Moreover, although the representative has suggested that the examiner failed to use the "at least as likely as not standard," the June 2013 VA examination report directly contradicts this assertion as the examiner specifically opined that the Veteran's PTSD was "less likely than not" incurred in or caused by the confirmed in-service stressors. The Board has also considered the Veteran's statements purporting to relate her currently diagnosed PTSD to her verified in-service stressor event. Upon review of the evidence of record, the Board finds that the Veteran's statements are not credible as they are inconsistent with, and outweighed by, other lay and medical evidence of record. Credibility can be generally evaluated by a showing of interest, bias or inconsistent statements; and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony are also factors that may be considered. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995). The Board emphasizes that the Court has recognized that personal interest to receive benefits may affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). In this regard, the Board notes that the Veteran has made numerous inconsistent and contradictory statements regarding the nature, extent and severity of her psychiatric symptoms during the pendency of this appeal, revising her statements in an attempt to associate her current psychiatric problems to her time in service. For example, at her Board hearing the Veteran testified that she never sought psychiatric counseling in service because she did not think that she had any problems. She reported first realizing that there was something wrong in approximately 2002, and that after doing some research, she realized that she had all the symptoms described for PTSD, including hypervigilance and panic attacks. However, after a meticulous review of all of the medical treatment records of record, the Board has not found a single complaint or report of hypervigilance or panic attacks. Moreover, the JMR failed to identify any such symptoms. Similarly, while the Veteran testified that she had vivid, recurring nightmares and flashbacks related specifically to her experiences in service several times a week, she never described or reported any such symptoms related to service to any healthcare provider at anytime during the pendency of this appeal, including when examined by VA in 2007. Most of the treatment records indicated that she gave a "vague" description of her nightmares and flashbacks. On the few occasions when she did describe her nightmares and flashbacks, the Veteran reported that they were about the abuse she suffered as a child and of witnessing the rape of her sister. At one point, she reported having vivid flashbacks of parts of an incident in which she was raped while living with her father, and said that she had them over and over, daily. See November 2006 VA treatment note. However, on other occasions, she reported that she could not recall whether she was ever sexually abused as a child. See February 2007 VAX. In any event, other than at the personal hearing, the Veteran never described any nightmares or flashbacks related to her service experiences at anytime during the pendency of this appeal. Further, although the Veteran was treated for psychiatric problems on numerous occasions since May 2005; as described above, she never mentioned any symptoms or problems related to her service experiences as a photographer until more than two years after she first sought psychiatric help. See July 2007 treatment note. Even then, the Veteran did not relate her current psychiatric problems to any incident in service, and said only that when she hears a child cry, it reminds her of a child she photographed in service that had been abused. She reported being physically, sexually and emotionally abused as a child and believed that this was part of her PTSD. The fact that the Veteran would recognize that she had PTSD or at least some symptoms of PTSD in 2002, which she believed was related to service, but did not report any such symptoms as being related to service until some five years later - and more than two years after she initially sought psychiatric treatment - is not believable or credible. For the reasons discussed above, the Board finds that the Veteran's alleged symptoms regarding her service experiences are self-serving and are not credible. Moreover, after taking into account the Veteran's reported history of symptomatology, the June 2013 VA examiner offered a probative medical opinion that the Veteran's PTSD was due to her childhood abuse and death of her fiancée. Additionally, while the Veteran was treated by several other psychiatrists over the years, most of those reports indicate that her current psychiatric problems were related to her childhood abuse. The evidence does not demonstrate that any treating healthcare provider suggested that the Veteran's current PTSD was incurred in or caused by her experiences in service. Based on the evidence of record, both lay and medical, the Board finds that the weight of the evidence is against a finding of relationship between the Veteran's currently diagnosed PTSD and her corroborated in-service stressor events. Accordingly, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for PTSD, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Other Acquired Psychiatric Disorders The evidence of record demonstrates that, in addition to PTSD, the Veteran has also been diagnosed with other psychiatric disorders, to include major depressive disorder, gender identity disorder, and personality disorder. As noted in the previous section, a psychiatric disorder was not noted at service entrance and service treatment records are negative for any diagnoses or treatment for major depressive disorder, gender identity disorder, and personality disorder. In the Report of Medical History for separation from service in July 1990, the Veteran specifically denied any history of trouble sleeping, depression or excess worry, memory problems or nervous trouble of any sort, and no pertinent psychiatric abnormalities were found on examination at that time. Review of the evidence of record reveals that the Veteran first initiated contact with mental health professionals in June 2002, where she related having been depressed since February 2002, 12 years after service separation. Importantly, the Veteran did not relate her depression to service, but instead, stated that it began when she left her wife to be involved in an alternative lifestyle. The Veteran did not follow-up on treatment until May 2005 when she was diagnosed with major depressive disorder and the focus of treatment was primarily related to her ex-wife. As noted in the previous section, in a November 2006 VA outpatient clinic note, the Veteran reported nightmares about children being beaten and her father harming her sister. She also reported the death of her fiancé in 1997 was very upsetting. She did mention in-service photos of women and children who were beaten, raped, and included a 4-year-old boy with bloody electrical cord marks across his back and chest. At that time, she was having problems with sleep, concentration, depression, dreams, and anger which was said to have started at age 10. Subsequently, in December 2006, the Veteran was diagnosed dysthymic disorder. The Veteran continued to seek VA psychiatric treatment approximately once per month, the focus of which was predominantly related to childhood abuse. The Board finds that VA treatment notes of record document an extensive and complex mental health history; however, they do not provide a medical opinion as to the etiology of the Veteran's depression. In efforts to obtain a medical opinion on the question of whether the Veteran's psychiatric disorders were etiologically related to service, the Veteran was afforded a VA examination in February 2007. Upon review of the claims file and mental status examination, the examiner, in pertinent part, diagnosed gender identity disorder, depressive disorder (in remission), and personality disorder, with histrionic and narcissistic traits. The VA examiner opined that none of these psychiatric disorders were related to service. In support of this opinion, the February 2007 VA examiner reasoned that there was no evidence during the examination that the Veteran was suffering from depression. According to the examiner, the suicidal note that the Veteran gave to a counselor in August of 2006 was for attention seeking behavior as the Veteran had a pattern of behavior that would be inferred as narcissistic and/or histrionic. It was noted that, since her youth, the Veteran seemed to have had a pattern of seeking attention suggesting a character or personality disorder. The examiner further noted that the Veteran also appeared to be troubled about gender issues. The examiner explained that the Veteran seemed ambivalent and was not aggressively seeking the process with the proper experts to initiate these changes. The Board finds the February 2007 VA medical opinion highly probative as the examiner interviewed the Veteran, reviewed the claims file, performed a mental status examination, and provided an opinion supported by a detailed rationale. In a subsequent June 2013 VA examination report, the VA examiner diagnosed the Veteran, in pertinent part, with personality disorder and gender identity disorder, which were found to be unrelated to events in service. Although it was noted that the Veteran continued to meet the criteria for a personality disorder diagnosis due to a pervasive pattern of interpersonal problems, inability to conform to some social norms, and limited adaptability to stressful environments, the personality disorder was found to be rooted in severe childhood abuse, and not service. The examiner opined that the psychiatric disorders were less likely than not incurred in or caused by the service. As previously noted, the Board finds that June 2013 VA medical opinion to be highly probative on the question of a possible nexus to service. The Board has considered the Veteran's statements purporting to relate her psychiatric disorders to service; however, for the reasons discussed in detail in the previous section, the Board finds that the Veteran's statements are not credible as they are inconsistent with, and outweighed by, other evidence of record. The Board also finds that although the Veteran has repeatedly been diagnosed with a personality disorder, a personality disorder is not service connected, and is subject to important restrictions regarding service connection. Governing regulations provide that personality disorders are not diseases within the meaning of applicable legislation providing for payment of VA disability compensation benefits. See 38 C.F.R. § 3.303(c), Part 4, § 4.9 (2013). For these reasons, the Board finds that the weight of the evidence of record demonstrates that the Veteran's diagnosed psychiatric disorders, to include major depressive disorder, gender identity disorder, and personality disorder, were not incurred in and are not otherwise etiologically related to service. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, major depressive disorder, gender identity disorder, and personality disorder, is denied. ____________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs