Citation Nr: 1801341 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 15-09 154 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for an acquired psychiatric disability, other than posttraumatic stress disorder (PTSD), to include anxiety and depression, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Smart, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from March 1976 to March 1980. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In June 2015, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing, a transcript of which has been associated with the claims file. The Board remanded this claim in July 2015, July 2016 and December 2016 for additional development. In the December 2016 decision the Board also denied entitlement to service connection for PTSD. In a May 2017 rating decision, the RO denied entitlement to service connection for a lung disability and tinnitus. The Veteran filed a notice of disagreement in October 2017 which was acknowledged by the RO in an October 2017 record. Therefore, the Board will refrain from remanding these issues at this time. Cf. Manlincon v. West, 12 Vet. App. 238 (1999). This appeal was processed using the Veterans Benefits Management System (VBMS). A review of the Veteran's Manager Legacy Documents file revealed VA treatment records dated August 2009 to September 2013 and the June 2015 Board hearing transcript. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. Given the inconsistencies in the Veteran's recollections, the unreliability of her statements as demonstrated by objective mental health testing, and the lack of contemporaneous documentation, it is unknowable whether the Veteran was assaulted in service. 2. Service connection is in effect for hypopigmentation of the skin and a gastroesophageal disability. 3. The Veteran's acquired psychiatric disability, other than PTSD, did not manifest during or as a result of active military service and is not etiologically related to a service-connected disability. 4. The Veteran's personality disorder was not subject to a superimposed disease or injury during service. 5. The Veteran's alcohol abuse was the result of the Veteran's own willful misconduct and is not otherwise the result of any service-connected disability. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, other than PTSD, have not been met. 38 U.S.C.A. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist VA has a duty to notify and assist pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. § 5103 (a) (2012); 38 C.F.R. § 3.159 (b) (2017). Here, neither the Veteran nor her representative has raised any issues with the duty to notify, and the Board finds no issue raised by the record. Regarding the duty to assist, the Veteran was afforded VA examinations in October 2013, September 2014 and October 2014. The Veteran was also afforded a VA addendum opinion in September 2016. The Board notes that in a November 2014 statement, the Veteran asserted that she believed the interviewer did not research her records of the past 30 plus years with the due diligence she deserves. She reported that she attempted to talk about how she felt all these years but the psychiatrist interviewer cut her short and refused to listen to her. Additionally at the June 2015 Board hearing, the Veteran also asserted that at the last compensation exam, the examiner did not allow her to talk about her skin condition. However, the Board notes that the Veteran did not raise any issues with the subsequent October 2015 VA examination and September 2016 VA addendum opinion provided. Therefore, the Board finds that there is no need for further examination or medical opinion to cure any perceived challenges that occurred previously. The Board also finds that the RO has substantially complied with the July 2015, July 2016 and December 2016 Board remand directives. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999); see also Stegall v. West, 11 Vet. App. 268 (1998). Analysis The Veteran contends that her acquired psychiatric disability, other than PTSD, is related to her military service, to include an in-service sexual assault. See June 2015 Board Hearing. The Veteran also contends that her acquired psychiatric disability, other that PTSD, is due to her service-connected hypopigmentation, neck and trunk and arms (skin disability) and/or her service-connected hiatal hernia with gastroesophageal reflux (GERD). See June 2015 Board Hearing. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131. Establishing service connection requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Turning to the evidence of record, the Veteran's service treatment records are absent of any complaints, treatment or diagnosis of an acquired psychiatric disorder. The Veteran's March 1980 separation report of medical examination shows that the Veteran's psychiatric was noted as normal. The Veteran's March 1980 separation report of medical history shows that the Veteran denied frequent trouble sleeping, depression or excessive worry and nervous trouble of any sort. A March 1980 statement of medical condition shows that the Veteran underwent a separation medical examination more than three working days prior to her departure from place of separation. She reported that to the best of her knowledge, since her last separation examination, there had been no change in her medical condition. The Veteran was afforded a VA skin diseases examination in November 1999. It was noted that the Veteran had psychological distress secondary to not being able to have the affected areas exposed to the public. In a February 2000 rating decision, the RO granted service connection for the Veteran's GERD. In an October 2001 rating decision, the RO granted service connection for the Veteran's skin disability. A March 2004 VA treatment record shows that the Veteran was treated after the end of her 15 year relationship. The VA social worker recommended that the Veteran seek psychiatric treatment at the nearest VA facility after she moves. Subsequent VA treatment records dated May 2005 to December 2008 show that the Veteran's problem list included depressive disorder, NOS and anxiety. In an April 2008 statement, a private nurse practitioner noted that the Veteran's GERD symptoms are distressing and disabling. An October 2011 VA treatment record shows that the Veteran was interested in switching her mental health treatment to VA as her insurance was running out. The Veteran reported that she had been feeling depressed for approximately one year due to the end of a romantic relationship and work related stress. She indicated she had experienced episodes of depression and anxiety throughout her life since childhood. The psychologist diagnosed major depressive disorder, recurrent, moderate; anxiety, not otherwise specified NOS; alcohol dependence, without physiological dependence, early partial remission and r/o somatization disorder. A March 2012 SSA examination shows that the Veteran denied any mental health problems prior to a 2011 work injury. She reported that she saw mutilated bodies as an x-ray technician in the military and "for a while this was a source of some difficulty." However, she indicated that she "no longer has nightmares or flashbacks associated with this." She was diagnosed with major depression, single episode, moderate, with anxiety and elements of PTSD. In a May 2013 PTSD stressor statement, the Veteran reported that in September 1977 she was separated from her group while attending Winefest at Bad Durkheim, West Germany. She reported that she was assisted to the Red Cross tent where they called the MPs to come and pick her up. She reported that the MPs took her to Mannheim where she waited for a ride back to Landstuhl. She reported that she went outside to wait for her ride when she was sexually assaulted by an Air Force member. She reported that they next thing she remembers was being driven back to Landstuhl. The Veteran was afforded a VA examination in October 2013. The Veteran described three in-service stressors. She reported that in September of 1977, she was assaulted by an Air Force member. She reported that she was intoxicated at the time and that she could not fully describe what had happened. The examiner indicated that it was "unclear per her description what truly happened in this event." The Veteran also described two other stressors related to her duties as an x-ray technician wherein she had to x-ray a small child who had been burned and a corpse. The examiner noted that she received an honorable discharge and her performance evaluations throughout her time in the military consistently indicate that her performance "ranks among the very best" and did not show any decline in work performance during her time in the service. The Veteran reported that she last worked in April 2011 with Southwest Airlines as an operations agent. She reported that she worked there for 13 years. She reported that a coworker "lowered a 600 pound door on my head". She reported that she sustained neck and upper back injuries and a "brain injury". She reported that she was on workman's compensation and eventually was forced to retire in May of 2012. She reported that she can no longer work because of physical injuries adding she was rear ended in an MVA in December of 2012 which further aggravated her work related injuries and so is no longer seeking employment. During this examination, the Veteran reported that she first sought mental health treatment in 2002 or 2004. The examiner noted that VA treatment records shows that the Veteran was first seen in October 2011 for mental health services. The examiner noted the October 2011 findings. The examiner noted that the Veteran did eventually endorse experiencing MST during her course of mental health treatment but it did not appear that this had been a primary focus of treatment. In regards to MMPI-2 validity, the examiner noted that the Veteran responded to items on the MMPI-2 in a careful and consistent manner, attending to item content and without adopting a fixed response approach. The examiner stated, however, that she responded to items in a highly unusual manner, endorsing many deviant items that genuine psychiatric patients do not endorse. The examiner concluded that her response pattern suggests deliberate exaggeration and potentially feigning of mental health symptoms and non-credible responding. The examiner explained that as a result, her profile was invalid and no further interpretations could be made. In regards to reliability and credibility of self-report, the examiner concluded that based on the evaluation, there was question and concern regarding the Veteran's credibility given her response on psychometric testing. The examiner explained that she is considered a non-credible responder, especially in regards to current mental health functioning. The examiner explained that the Veteran's psychological testing had validity scale measures well above cut-offs, representing strong evidence of symptom exaggeration to the point where making an accurate mental disorder diagnosis unlikely, and cannot be done without resorting to speculation. The examiner explained, in relevant part, that given results of psychometric testing, along with a complicated clinical presentation marked by significant personality disorder characteristics, depression and substance abuse, an accurate diagnosis was unable to be rendered for compensation purposes without resorting to speculation. In a February 2014 statement, Dr. P, a private psychiatrist, noted that the Veteran reported a history of traumatic events that date back to early childhood. Dr. P noted that the Veteran indicated she experienced varying forms of abuse throughout her life, but indicated that the most traumatic events occurred while she was in the military. Dr. P noted that the Veteran indicated being raped in the military and the nature of her job as an x-ray technician still impact her to this day. The examiner diagnosed PTSD but did not address the etiology of the Veteran's acquired psychiatric disorder, other than PTSD. In a March 2014 statement, the Veteran's sister C.W reported that when the Veteran would come home on leave, her behavior was loud, sometimes obnoxious and she was into heavy drinking. C.W reported that she was not pleasant to be around and they did not know what to expect from her embarrassing mannerisms. C.W reported that the Veteran did not act like this before she went to Germany. In an April 2014 statement, the Veteran's sister W.K reported that in June 1978 when the Veteran came home briefly for her wedding, the Veteran's eyes were "haunted". She reported that the Veteran looked like a tortured individual. W.K reported that years later the Veteran confided in her that she had been raped while stationed in Germany. W.K reported two events in the 1980s concerning the Veteran's drinking. In a July 2014 statement, the Veteran's sister D.E reported that the Veteran was never the same person when she returned from the service in Germany. She reported that none of them knew of the trauma she suffered in the military but knew something was not right. In a July 2014 statement, C.W reported that she first noticed the Veteran's skin discoloration on her forearms during family gatherings in 1978. She reported that prior to this, the Veteran was outgoing, social and participated in outdoor activities with family and friends. She reported that the Veteran's normal attire was generally shorts and short sleeve shirts. She reported that the Veteran began not to participate in family or friend outdoor and swimming gatherings. She reported that going out in public, the Veteran constantly wore long sleeves, even on days when it would have been considered by many too hot. She reported that the Veteran's attitude would go from one extreme to another when asked why she was not participating and/or wearing the long sleeves when it was so hot. C.W reported that the Veteran seemed not only embarrassed but very concerned about her appearance. She reported that the Veteran would become withdrawn and appeared depressed and distressed. In a July 2014 statement, W.K reported that when the Veteran came home on leave in 1978 she noticed white patches of discoloration on her forearms and asked about it. She reported that the Veteran was very self-conscious about her skin patches and did not want to talk about it. She reported that once the Veteran's skin condition progressed and worsened the Veteran would not take part in any family pool parties, beach gatherings or any other activity that involved exposing her arms and upper chest to view. W.K reported that the Veteran seemed to be embarrassed and when asked what was wrong she would become hostile and belligerent and would walk away to isolate herself. She reported that often when family and friends were outside around the family pool, the Veteran was inside around the television. She reported that the last time she saw the Veteran was in California in 2013. She reported that it was 103 degrees outside and the Veteran was in a long sleeved cotton shirt and was still self-conscious of her appearance. The Veteran was afforded a VA examination in September 2014. The examiner diagnosed unspecified depressive disorder. The examiner also diagnosed cluster B personality traits (r/o borderline personality disorder). The examiner noted the October 2013 VA examination. The examiner noted that the reliability and credibility of self-report was questionable. The examiner explained that the Veteran perseverates about how she has been victimized throughout her life and appears to externalize blame to others for her current difficulties. The examiner concluded that the Veteran's depressive disorder was not caused or aggravated by her service-connected skin condition. The examiner noted that the Veteran's depressive disorder was not caused or aggravated by her skin condition. The examiner explained that rather, VA mental health treatment records overwhelmingly indicate that her mood difficulties are related to significant dysfunction in family-of-origin relationships, including a childhood history of sexual and physical abuse, difficulty in romantic relationships, chronic pain stemming from a work injury in 2011 and significant financial distress and prominent features of personality disorder. In a November 2014 statement, the Veteran asserted that in 1991, she had a VA examination done by a dermatologist which stated that she had anxiety secondary to her service-connected skin disorder condition. She reported that since 1977 she has worn long sleeve shirts in an attempt to fit in. She reported that when she wore short sleeve shirts she received stares and it affected her interaction with people. At the June 2015 Board hearing, the Veteran testified that prior to service she did not have any mental health problems. She reported that she was outside and active with hiking, backpacking and swimming. The Veteran reported that she was sexually assaulted in Manheim while waiting for transfer in either September 1977 or September 1978. She reported that during this time she also started having issues with both of her forearms being swollen and red. She reported that she started wearing the green wool sweaters that were issued year round. The Veteran reported that her performance reviews improved after her assault because that was her way of dealing with what happened. She reported that she started self-medicating with alcohol. She reported that in 1978 she requested transfer to San Diego to attend ultrasound school. The Veteran reported that from the time she got out of service, she was having trouble with her skin and mental health condition. She reported that she was drinking heavily. She reported that she was wearing long-sleeved shirts on all of her jobs because she felt self-conscious. She reported that the disfigurement attacked her self-esteem. The Veteran reported that she was first treated for anxiety in 1991. She testified that she did not seek mental health treatment while she was employed with Southwest because she was afraid of losing her job. She testified that in 2004 a doctor at the Reno VAMC put her on medication for anxiety and depression. She reported that she was treated for anxiety in 2008 at the Philadelphia VAMC. The Veteran reported that she started receiving treatment in 2009 at the Minneapolis VAMC. She reported that at her compensation examination in 1999, the examiner stated her mental health condition was related to her skin condition. The Veteran was afforded a VA examination in October 2015. The examiner diagnosed other unspecified depressive disorder with anxious distress and other unspecified personality disorder with borderline personality characteristics. The Veteran reported a stressor of being assaulted in Germany in September 1977 or 1978. She reported that she was intoxicated and fell into a street and hurt her knee. She indicated that she remembered "somebody coming at me." She reported that she was uncertain if there was an assault. The examiner concluded that the Veteran's anxiety/depressive symptoms are best accounted for as secondary to the negative consequences of her alcohol abuse and severe personality pathology that interfered with her emotional regulation and relationships. The examiner explained that the Veteran's clinical presentation is characterized by maladaptive personality traits, which predispose her to reactive symptoms, including anxiety and depression symptoms. The examiner explained that despite displaying and reporting symptoms of depression and anxiety, her primary underlying problem is problematic personality structure and the symptoms of depression and anxiety that she may experience are more likely than not the result of her deficient personality structure. The examiner explained that this renders her to be deficient in her ability to cope, to manage emotions and conform behavior to social expectations. The examiner explained that as a result, the primary clinical presentation for the Veteran was that of personality disorder. The examiner explained that with regard to the reports of behavioral changes, the point is somewhat moot given that PTSD was not diagnosed and the presence of an assault cannot be determined without resorting to mere speculation. The examiner noted that the alleged behavioral changes reference "self-medication with alcohol" and increasing her work habits. The examiner noted these assertions of evidence of an assault should be considered with significant caution. The examiner noted that the Veteran's self-report is unreliable and evidence gathered via three administrations of the MMPI2 establishes a pattern of non-credible responding. The examiner noted that with that said, the assertion of "self-medication with alcohol", specifically with this Veteran, is inconsistent with the Veteran's self-report given that she admits that she had been drinking heavily and blacked out at the time of the alleged assault. The examiner noted that generally speaking, it can be quite challenging to identify the origins of affective and behavioral symptoms within individual using substances. The examiner noted that it is not uncommon for clinicians to conclude that substance use is a "self-medication" of psychological distress and, therefore, any reported symptoms (i.e., depression, anxiety, etc.) stem from the source of psychological distress. The examiner noted that however, the self-medication hypothesis, originated by Khantzian in 1985, has not been well supported in the literature. The examiner noted that as Lembke (2012) wrote, "although originally formulated as a compassionate explanation for addiction in those with psychiatric disorders, the SMH does not provide, as originally intended, a 'useful rationale' for guiding treatment and instead has led to under-recognition and under-treatment of substance use disorders." The examiner explained that it is quite clear from a review of Veteran's records that her history of alcohol dependence dominated her clinical presentation for many years, overshadowing any symptoms or impairment that would be secondary to an anxiety or depressive disorder. The examiner noted that the impact of the Veteran's substance misuse in functional impairments is difficult to gauge, as she has likely minimized this issue and may not be considered an accurate reporter in this respect. The examiner explained that further, the presence of maladaptive personality characteristics may also contribute to adjustment and interpersonal difficulties. The examiner noted that it is not uncommon for treatment providers to mistake symptoms of chronic substance abuse with depressive disorders, anxiety disorders, and personality disorders. The examiner explained that depression and anxiety can both be substance-related conditions biochemically. For example, insomnia, autonomic hyperactivity (similar to a panic attack), psychomotor agitation, and anxiety are all symptoms of withdrawal from alcohol or sedatives. Stimulant withdrawal (i.e., cocaine or amphetamines) can cause nightmares, insomnia, and either psychomotor agitation or retardation. Cannabis withdrawal can result in irritability, anxiety, sleep difficulty, and a depressed mood. The examiner explained that substance abuse can also lead to symptoms of pathology that are not easily categorized. The examiner explained that this is because of the variance in substance type, dosage amounts, dosage frequencies, and constitution of the substance users. Within each substance abuser, these variables group to produce physiological responses (irritability, anxiety, depression, etc.) that can lead to misdiagnoses. The examiner noted that there are numerous challenges inherent in assessing the validity of self-report from individuals who abuse substances. The examiner noted that factors often exist that would reinforce the conscious under-reporting of substance use for impression management (i.e., legal matters, effects on services or financial gains, shame, etc.). The examiner noted that these individuals may also lack awareness of the quantity and frequency of their substance use, particularly if it has become a routine part of their lives The examiner also concluded that as previously explained the Veteran's depressive disorder is unlikely etiologically related to military service. The examiner explained that setting questions of reliability/credibility aside, the Veteran fairly consistently claimed onset of most symptoms in 2011 after a work related accident. The examiner also concluded that it is less likely than not that the Veteran's depressive disorder is related to or caused by her service-connected skin disability or gastrointestinal disability. The examiner explained that records consistently related depression/anxiety symptoms as secondary to other factors and onset was reportedly not until well after the military. The examiner also concluded that the Veteran's depressive disorder was not aggravated beyond its natural progression by the service-connected disability or gastrointestinal disability. The examiner explained that first; the reported onset of depression/anxiety symptoms was not until well after the onset of the service connected disabilities. The examiner explained that second, there is no "natural progression" of depression/anxiety symptoms. The examiner noted that in regards to MMPI2-RF validity, overall, the pattern is consistent with individuals who grossly exaggerate and/or malingering symptoms in order to achieve some secondary gain. The examiner also concluded that the Veteran's self-report is deemed non-credible. The examiner explained that the Veteran's MMPI2-RF was invalid for exaggerating symptoms. The examiner stated of note, this is the third MMPI2 the Veteran has completed (10/09/2013, 04/16/2014) and each one has been invalid due to exaggerated responding. The examiner explained that overall, the Veteran presents as being prone to exaggeration, presenting as victimized and making attributional errors. A June 2016 VA treatment record shows that a staff psychiatrist stated that his medical opinion at the time was that the Veteran's report appeared credible and would imply that emotional difficulties over time including borderline behaviors have root in negative events that occurred in Germany while serving in the military. It appears at least as likely as not that depressive symptoms are directly related to events while serving in the military in Germany. The Veteran was afforded a VA addendum opinion in September 2016. The examiner noted that it is less likely as not that the depressive disorder diagnosed on exam in October 2015 is related to service. As noted in the original report, onset appears well after military service. The examiner concluded that it was unlikely that the Veteran's depressive disorder is related to or caused by her service connected skin disability and/or gastrointestinal disability. The examiner noted that the exam in 1999 states, "she denied any pain or pruritus, but she has psychological distress secondary to not being able have these areas exposed to the public." The examiner explained that the term "psychological distress" is an ambiguous term that does not necessitate that this equates to a psychological "disorder." The examiner explained that the term "distress" may be synonymous with other general expressions of dissatisfaction. The examiner stated that however, there is no other documentation of clinically defined mental health symptoms in that report to suggest that this "psychological distress" rises to the level of a mental health disorder. The examiner explained that this is a similar finding to the report in 2008 that notes "epigastric distress", which is not mental health related, and that she finds the symptoms "distressing and disabling." The examiner stated that again, distressing is used in an ambiguous manner with no descriptions of the distress that would describe a mental health disorder. The examiner also concluded that it was less likely as not that the Veteran's acquired psychiatric disorder was aggravated; permanently worsened beyond its natural progression, by the Veteran's skin disability and/or gastrointestinal disability. The examiner stated that first; there is no "natural progression" for mental health disorders. The examiner stated that second, the reliability of the Veteran's self-report is highly questionable. The examiner explained that as noted in the original exam, the Veteran has produced invalid MMPI2 profiles due to clearly exaggerated symptom claiming. The examiner stated that finally, there are other factors that are more likely contributing to the Veteran's subjective claims of distress, i.e., personality factors. The examiner noted that the family member lay statements were reviewed and considered as part of the exam. The examiner explained that though they describe some observed changes in the Veteran, this does not provide sufficient details to determine whether the Veteran met criteria for a mental health disorder at that time. The examiner stated that additionally, it does not help to differentiate between any genuine mental health symptoms vs substance induced symptoms. The examiner explained that with regard to the VA provider's opinion regarding the Veteran's symptoms, it should be noted that the original compensation exam in October 2015 discussed this very concern regarding dual relationship boundaries by providers opining on forensic claims, such as compensation exams. The examiner explained that although the provider believes that the Veteran's current mental health symptoms are secondary to events in Germany and the Veteran's skin lesions, the provider does not fully account for the evidence. The examiner stated that first, the provider states that "her report appears credible" which is contradictory to the evidence. The examiner explained that the Veteran has completed three administrations of the MMPI2 and invalidated them all due to over-reporting. The examiner explained that the MMPI2 has more scientific evidence supporting its ability to differentiate between genuine reporting and exaggerated reporting than clinical intuition which has been shown to be wholly unreliable. The examiner stated that additionally, the assertion that the Veteran's alcohol abuse began after her alleged military assault ignores that she was heavily intoxicated at the time, does not clearly remember the alleged incident, and stated in the C&P exam that she is uncertain if she was actually assaulted or not due to blacking out from alcohol. The examiner noted that finally, the provider stated that "emotional difficulties over time including borderline behaviors have root in negative events that occurred in Germany while serving in the military." The examiner explained that personality disorders by definition are developmental in nature and do not initially manifest secondary to a particular incident. The examiner explained that they have to do with chronic characterological features that negatively influence how an individual interacts with others and views the world around them. Based on the above, the Board finds that the evidence of record is against a finding of service connection for an acquired psychiatric disorder, other than PTSD. In this regard, the Board finds the October 2015 and September 2016 VA medical opinions, when taken together, to be highly probative to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the October 2015 and September 2016 VA opinions were provided by a VA psychologist who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinions are shown to have been based on a review of the Veteran's pertinent records and history, and are accompanied by extensive explanation that addresses both direct and secondary service connection. The opinions, when taken together, adequately address the lay statements and other medical evidence of record. The Board thus finds that the VA opinions, when taken together, are dispositive of the nexus question in this case. The Board acknowledges the November 1999 VA examination and April 2008 private treatment record that noted the Veteran's skin caused psychiatric distress and that the Veteran's GERD symptoms were distressing. However, the examination and private treatment record do not provide a diagnosis of an acquired psychiatric disorder due to the Veteran's skin symptoms and GERD symptoms. Additionally, as noted above, in the September 2016 VA opinion, the examiner noted that "distressing" is used in an ambiguous manner with no descriptions of the distress that would describe a mental health disorder. As such, the Board assigns the November 1999 VA examination and April 2008 private treatment record little probative value in determining whether the Veteran's acquired psychiatric disorder, other than PTSD, warrants service connection on a secondary basis. The Board also acknowledges the positive June 2016 opinion from a VA staff psychologist. However, the Board finds that the VA provider failed to reconcile his conclusions with the other evidence of record. As noted in the September 2016 VA opinion, the VA staff psychologist's conclusion that the Veteran's reports are credible is contradictory with the evidence of record that shows that the Veteran has completed three administrations of the MMPI2 and invalidated them all due to over-reporting. The September 2016 examiner also noted that the assertion that the Veteran's alcohol abuse began after her alleged military assault ignores that she was heavily intoxicated at the time, does not clearly remember the alleged incident, and stated in the compensation exam that she is uncertain if she was actually assaulted or not due to blacking out from alcohol. Furthermore, in regards to the provider's conclusions regarding borderline behaviors, the September 2016 examiner explained that personality disorders by definition are developmental in nature and do not initially manifest secondary to a particular incident. Finally, the September 2016 VA examiner noted that the original compensation exam in October 2015 discussed dual relationship boundaries by providers opining on forensic claims, such as compensation exams. As such, the Board assigns the June 2016 VA provider opinion little probative value in determining whether service connected is warranted for the Veteran's claimed disability. The Board acknowledges the Veteran's lay assertion that the acquired psychiatric disorder, other than PTSD, is related to her military service and/ or her service-connected skin disability and GERD. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, determining the etiology of a complex psychiatric picture, falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset of symptoms and personal observations, any opinion regarding the nature and etiology of her disability requires medical expertise that the Veteran has not demonstrated because the cause of the Veteran's acquired psychiatric disorder may be due to multiple causes thereby requiring medical expertise to discern the cause. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As such, the Board assigns no probative weight to the Veteran's assertions that her disability is in any way related to her military service or to her service-connected disabilities. The Board also acknowledges the Veteran's sisters observations regarding Veteran's behavioral changes during and after the military. However, the September 2016 VA examiner concluded that these reports do not provide sufficient details to determine whether the Veteran met criteria for a mental health disorder at that time. The examiner stated that additionally, it does not help to differentiate between any genuine mental health symptoms vs substance induced symptoms. Additionally, the Board notes that the similarities between the Veteran's current symptoms and those she experienced in service and after may be relevant to an expert considering potential causes of the Veteran's current condition; however, lay observation of this similarity alone is not competent evidence of causation. Here, the probative September 2016 VA opinion shows that the Veteran's behavioral changes are not related to her currently diagnosed acquired psychiatric disorder, other than PTSD. Thus, to any extent that the Veteran and her sisters contend that the symptoms the Veteran has experienced over the years are part of a continuing disease process of symptoms experienced in service, the medical expert has determined that this in fact is not the case. As such, the Board assigns little probative weight to the lay statements regarding the Veteran's behavioral changes in determining the nature and etiology of the Veteran's condition. In regards to presumptive service connection and continuity of symptoms, the Board notes that while the general term "psychoses" is recognized as a chronic disability for VA purposes, this term is specifically limited to a certain set of specific psychiatric disabilities or disorders. 38 C.F.R. § 3.384. None of the Veteran's currently diagnosed disorders, to include depressive disorder and anxiety, NOS, are noted to be included under the term "psychoses" and are not otherwise listed as recognized chronic diseases. The Board thus finds that service connection based on the presumption in favor of chronic diseases and based on continuity of symptomatology are not applicable in this case. Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303 (b), 3.304, 3.307(a), 3.309(a), 3.384. The Board notes that the Veteran has been diagnosed with a personality disorder. Personality disorders are not considered "diseases or injuries" within the meaning of applicable legislation and do not constitute disabilities for VA compensation purposes. See 38 C.F.R. §§ 3.303 (c), 4.9, 4.127. Thus, service connection for a personality disorder is precluded by law. See Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that 38 C.F.R. § 3.303 (c), as it pertains to personality disorder, is a valid regulation); see also O'Bryan v. McDonald, 771 F.3d 1376, 1380 (Fed. Cir. 2014) (a "defect" is not subject to the presumption of soundness under 38 U.S.C. § 1111). Furthermore, while service connection may be granted, in limited circumstances, for a disability due to aggravation of a constitutional or developmental abnormality by superimposed disease or injury, such has not been indicated in this case and is not applicable. See VA Gen. Coun. Prec. 82-90, 55 Fed. Reg. 45, #711 (1990). Instead, the most probative evidence of record suggests that the Veteran's symptoms are characteristic of her personality disorder. Finally, the Board notes that the Veteran has been diagnosed with substance abuse disorder, specifically alcohol dependence. As it relates to the substance abuse diagnoses, direct service connection may not be granted for a disability resulting from the veteran's own drug or alcohol abuse. 38 U.S.C.A. § 105; 38 C.F.R. § 3.301 (a), (b), (c)(3); VAOPGCPREC 7-99 (June 9, 1999). The Board acknowledges service connection on a secondary basis is permissible if it as acquired as a symptom of, or secondary to, another service-connected disability. However, in this case the most probative evidence of record does not suggest that the Veteran's substance abuse is secondary to a service-connected disability. Instead, the October 2015 examiner explained that it is quite clear from a review of Veteran's records that her history of alcohol dependence dominated her clinical presentation for many years, overshadowing any symptoms or impairment that would be secondary to an anxiety or depressive disorder. The examiner noted that the impact of the Veteran's substance misuse in functional impairments is difficult to gauge, as she has likely minimized this issue and may not be considered an accurate reporter in this respect. As such, further discussion is unnecessary. See 38 C.F.R. § 3.310; see also Allen v. Principi, 237 F.3d 1368, 1375 (2001). As such, based on the above, the Board finds that the weight of the evidence is against a finding of service connection. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102 (2015), Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for an acquired psychiatric disability, other than PTSD, is denied. ____________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs