Citation Nr: 1807832 Decision Date: 02/07/18 Archive Date: 02/20/18 DOCKET NO. 14-23 869 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Y. Lee, Associate Counsel INTRODUCTION The Veteran had active duty service with the United States Army from October 1990 to June 1998. She was originally given an honorable discharge for the period of service from October 30, 1990, to December 7, 1996, and an undesirable discharge from December 8, 1996, to June 16, 1998. In August 2001, the Veteran's discharge was upgraded to general (under honorable) conditions for the period of service from December 8, 1996, to June 16, 1998. Thus, the Veteran's entire period of active duty service was under honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied entitlement to service connection for PTSD. Jurisdiction of the matter is now with the RO in Detroit, Michigan. In December 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's electronic claims file. The Board notes that prior to her current representation, the Veteran was represented by the Tennessee Department of Veterans' Services (TDVS). VA received a signed VA Form 21-22 in November 2017, changing representation from the TDVS to The American Legion. (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. The Veteran does not have a valid diagnosis of PTSD consistent with the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) criteria. 2. The Veteran does not have an acquired psychiatric disorder other than PTSD that manifested in service, a psychosis that developed within one year thereafter, or an acquired psychiatric disorder that is otherwise related to her military service, including military sexual trauma (MST). CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102 , 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Procedural Duties VA has completed the necessary steps in order to meet its duties to notify and assist under the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran has not raised any procedural arguments regarding the notice or assistance provided. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA sent VCAA letters to the Veteran, she was afforded a VA examination, and her in-service and post-service medical records were obtained. The examination and opinion, taken together, are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any additional outstanding evidence which could be obtained to substantiate her claim, and the Board is unaware of any such evidence. Therefore, the Board finds that the duties to notify and assist have been met. II. Service Connection The Veteran is seeking service connection for an acquired psychiatric disability, to include PTSD due to military sexual trauma (MST). She asserts that she felt pressured to have unwanted sexual relationships with superior officers. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (West 2014). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). In addition, for certain chronic diseases, such as psychoses, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307 , 3.309(a). The presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. § 3.309, 3.309(a). When chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 49. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Also, 38 U.S.C. § 1154(a) requires that VA give 'due consideration' to 'all pertinent medical and lay evidence' in evaluating a claim for disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, '[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.' Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on her behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Also, an increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 38 C.F.R. § 3.310(b); Libertine v. Brown, 9 Vet. App. 521 (1996); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). An appellant's own conclusion, stated in support of his claim, that his present disability is secondary to his service-connected disability is not competent evidence to the issue of medical causation. See 38 C.F.R. § 3.159 (2016); see also Grivois v. Brown, 6 Vet. App. 136 (1994). There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. Per 38 C.F.R. § 4.125(a), a diagnosis of a mental disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association (2013). During the course of the appeal, the regulations for PTSD were amended to include that if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "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, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 38 C.F.R. § 3.304(f)(3); 75 Fed. Reg. 39843-39852 (July 13, 2010). Initially, the Board notes that there is no evidence in the record that the Veteran served in combat nor is the Veteran claiming that she served in combat or that her PTSD is related to combat. Further, as the Veteran did not serve in a location involving "fear of hostile military or terrorist activity," the amended regulations are not for application. Rather, the Veteran's principal claimed stressor is that she was victim of unwanted sexual advances while in service. Thus, as it is not shown that the Veteran engaged in combat, her unsupported assertions of service stressors are not sufficient to establish the occurrence of such events. Rather, her alleged service stressors must be established by official service records or other credible supporting evidence. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet.App. 128 (1997); Doran v. Brown, 6 Vet.App. 283 (1994). The regulatory requirement for "credible supporting evidence" means that "the veteran's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor." Dizoglio v. Brown, 9 Vet. App. 163 (1996). VA's regulation concerning the evidence necessary to establish the occurrence of a stressor in claims for service connection for PTSD provides the following guidance: If a post-traumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. §3.304(f)(5). Evidence of behavioral changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a post-traumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. Id. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for an acquired psychiatric disorder, to include PTSD. In various statements submitted with her claim for PTSD, the Veteran has identified the primary events that she considers being the precipitating cause of her PTSD, specifically during basic training and Advanced Individual Training (AIT); she was sexually mistreated by superiors. See December 2010 statement. However, the critical element in this case is that, based on the record as a whole, the Veteran lacks a diagnosis of PTSD consistent with the DSM criteria. Furthermore, the in-service stressor that the Veteran has asserted to be the cause of her claimed PTSD has not been verified. Service treatment and service personnel records are silent with respect to any incidents of military sexual trauma. Moreover, such records are negative for evidence of a psychiatric disorder, including PTSD. Significantly, in May 1998, while in service, the Veteran underwent a mental status evaluation; however, her mental status at that time was within normal limits, and no pertinent diagnosis was noted. Furthermore, the Veteran's separation examination report shows no psychiatric abnormality. In addition, the Veteran's service personnel and treatment records do not document any behavioral changes corroborating the alleged incidents of military sexual trauma. Indeed, there is no indication that the Veteran's work performance diminished during her military service. Rather, her record indicates several promotions. There is also no indication that the Veteran had a need for continued or ongoing medical care due to any acute psychiatric symptoms in the immediate years after her separation from service in June 1998. In fact, a September 2006 VA treatment record indicates that the Veteran's screening for PTSD was negative. Post-service, the earliest clinical indication of the presence of potentially chronic psychiatric symptomatology are VA records dated in June 2010, approximately 12 years following the Veteran's discharge from active service, at which time the Veteran reported persistent difficulty relating with others, resulting in her leaving several jobs due to interpersonal conflicts. She further reported that this has been most problematic since she was required to leave the Army in 1998 after a positive marijuana screen. The Veteran indicated great difficulty in adjusting after this. She also reported that her time in the military involved frequent interpersonal conflicts and stated that she often was the victim of inappropriate sexual advances by men, one of whom lost his job after harassing her. The Veteran also noted a history of sexual abuse by her youngest brother's father that began at age 5 and lasted several years. Likewise, in July 2010, the Veteran again reported sexual trauma as a young child, and at this time, she also indicated that she had experienced numerous instances of MST while in service, starting in basic training. She reported that she and other women were targeted by drill sergeants and called out - they used pressure tactics, authority, and punishing drills for refusals to have sexual encounters. The Veteran also reported another instance in one of her training courses where a male authority figure was removed from the military, which the Veteran believed to be due to his sexual misconduct with female soldiers. The Veteran also reported that she was attacked by a male soldier and raped. Later, in December 2010, the Veteran submitted a statement providing further detail to the encounters as described during the July 2010 VA outpatient treatment. The Veteran indicated that during basic training in December 1990, she was taken to her senior drill sergeant's home with her roommate, and was sexually abused. She further stated that she participated in official investigations into allegations made by other soldiers regarding the December 1990 incident. See December 2010 statement. The Board notes that in December 2011, VA made efforts to obtain investigative reports of the sexual abuse incidents in-service, as reported by the Veteran, from the U.S. Army Crime Records Center. In response, the U.S. Army Crime Records Center indicated that there were no such investigative reports. The Board further notes that the record makes no note of the Veteran's alleged incident of being attacked and raped by a male solider. Notably, during the December 2017 hearing, the Veteran made no mention of this alleged incident in her testimony. Furthermore, with regard to the December 1990 incident, inconsistent with her December 2010 statement where she indicated that she was sexually abused by her drill sergeant, the Veteran testified that she sat outside the bedroom where her roommate and drill sergeant went in. At the time of the July 2010 VA outpatient treatment, the Veteran was diagnosed with PTSD and was recommended to seek psychotherapy. During the course of VA outpatient treatment from July 2010 to August 2016, the Veteran was diagnosed with PTSD. An October 2013 VA treatment note provided a diagnosis of PTSD, secondary to MST. However, none of the treatment records which provide a PTSD diagnosis include a specific discussion of the DSM criteria. Based on the VA outpatient treatment records, the Veteran's primary symptomatology appeared to be agitation, obsessive compulsive disorder, and depression. The Veteran was afforded a VA examination in September 2016, where the psychologist reviewed the claims file, including service and post-service treatment records, as well as the Veteran's post-service psychiatric history. The September 2016 VA psychologist ultimately concluded that the Veteran did not meet the DSM-5 stressor criteria and did not meet the DSM-5 criteria for a diagnosis of PTSD. The examiner provided a diagnosis of definite maladaptive personality characteristics, rule out personality disorder. When questioned regarding her pre-service history, the Veteran indicated that she had grown up in an apparently dysfunctional family. She was raised by "lots of people". The Veteran indicated that her mother was abusive, and she grew up feeling as though her mother did not love her. She also indicated that she ran away at age 14 to her grandmother's house. Reportedly, when the Veteran was 5 years old, her mother married the Veteran's little brother's father. The Veteran indicated that she was told that while her mother worked late at night, her stepfather would get her out of bed and take her to her mother's bed. The examiner noted that the Veteran sought post-service psychiatric outpatient care, starting in June 2010. From July 2010 through November 2010, the Veteran received psychotherapy. The examiner noted that the Veteran began psychotherapy with Dr. M.S. in March 2013. The examiner further noted that no therapy is noted in the VA treatment records from 2013 through 2016. When specifically questioned regarding her military stressors, the Veteran indicated that she was "being forced to have sex with drill sergeant in basic training." She also indicated that she was forced by another authority figure in AIT to have sex with him. However, and as previously noted, there were no records indicating that the Veteran received medical treatment following these incidents, which she initially indicated that she did not report. Significantly, somewhat later, as indicated in her December 2010 statement, the Veteran stated that she had discussed the aforementioned incidents with her platoon leader, who had counseled her not to file charges; however, the Veteran indicated that official investigations as to the aforementioned incidents were conducted. As previously noted, there is no record of these investigations. The September 2016 VA examiner noted several significant inconsistencies with the Veteran's prior statements of record. The examiner noted that in April 2016, the Veteran denied any pre-military history of physical and sexual abuse; however, in June 2010, as noted above, she reported a history of sexual abuse starting at age 5 and lasting several years. Another notable inconsistency noted by the examiner was with regard to the alleged MST incidents. The examiner specifically noted that in her December 2010 statement, the Veteran indicated that she was taken to the home of the drill sergeant with her roommate and forced to have sex. The examiner further noted that the Veteran reported being under mental stress due to having to lie during official investigation into allegations made by other soldiers about the drill sergeant and her roommate. Then, as noted in the July 2010 VA treatment note, the Veteran reported that she and a few others were targeted by the drill sergeant who used pressure tactics for sex. At that time, she also reported an unwanted sexual encounter during AIT. The September 2016 VA examiner noted that in prior statements, the Veteran indicated that she had never reported alleged attacks; yet, in other statements, she noted that there were investigations and she was black-balled as a result of her involvement in the alleged incidents. Furthermore, as previously noted as well, the examiner noted that there are no records of the official investigations. Moreover, there is no report of the Veteran's experience of being attacked and raped by a male soldier, as she noted during the July 2010 VA treatment. As a result of these inconsistencies, the September 2016 VA examiner opined that she was unable to make a connection between the Veteran's current symptoms and MST. The examiner indicated that there are many unknown variables due to changes and differences in the facts/stories presented by the Veteran. There are no markers in military records that correspond to many of her comments. Overall testing suggested diagnoses of Borderline Personality Disorder, Major Depressive Disorder, and Adjustment Disorder. There is suggestion of multiple phobias. The examiner concluded that while there is a strong possibility of PTSD, the lack of veracity presented by the Veteran and the lack of markers in military records make it impossible to make an opinion without resorting to speculation. As such, the examiner indicated that she could only note that the Veteran exhibited several maladaptive behaviors and maladaptive personality deficits, given the information provided by the Veteran and a careful review of the Veteran's file and military records. The examiner concluded that she was unable to opine with any certainty that the Veteran's symptoms were related to any alleged incidents in the military. Thus, as noted by the September 2016 VA examiner, the Veteran's written and verbal accounts of having been sexually assaulted in service were inconsistent, calling into question the likelihood of the described sequence of events. Significantly, the Veteran did not show any deterioration in functioning following the alleged sexual assault, but in fact, showed an improvement in her military performance. Without corroborating evidence of the assault, the Veteran's military records were not consistent with personal trauma and the subsequent development of PTSD symptomatology. Moreover, there were no available records of mental health treatment between the time of her discharge from the military and her treatment at the local VA medical center in 2010, making it less likely than not that her military service aggravated a preexisting psychiatric disorder. Initially, the Board recognizes that there has been some indication that the Veteran may have a current psychiatric disorder related to incidents that occurred prior to her active duty. Nevertheless, regulations provide that 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. 38 U.S.C. § 1111. In the instant case, no chronic psychiatric disability was documented at enlistment. No chronic disability was noted at any point during service. As such, the Veteran is presumed to have been sound in condition with respect to any chronic psychiatric disability prior to her active duty. In turn, the primary question is whether the Veteran's current psychiatric disability had its onset in service, or is otherwise related to an injury or incident in service. In this regard, the Board observes that the Veteran is competent to report that she experienced her alleged stressors in service, and that she has experienced psychiatric symptoms since such time. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (holding that a claimant was competent to testify to chronicity and continuity of mental health symptoms); Culver v. Derwinski, 3 Vet. App. 292, 297-98 (1992) (holding that a claimant was competent to report a nervous breakdown that occurred shortly after service). Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, in the instant case, the Board finds that the Veteran's lay statements regarding the account of her alleged stressors to be not credible. In addition to evaluating competence, the Board has a duty to assess the credibility of the evidence of record. Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Although the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence of the in-service event - see Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) - the Board may discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). Here, the Board finds that the credibility of the Veteran's allegations pertaining to her in-service stressors is outweighed by the evidence to the contrary, which includes competent and probative medical opinion evidence and her own documented falsehoods. Importantly, there are no forms of alternative evidence that can be used to support her contention of MST under 38 C.F.R. § 3.304(f)(5). In this regard, there was no deterioration in work performance following the alleged MST incidents to support her claim. Despite an attempt to obtain investigative reports in connection with the alleged incidents, there are no such records. Moreover, there was no record of any diagnosis of a psychiatric disorder during service. In addition, as noted by the September 2016 VA examiner, the Veteran has been a highly inconsistent informant who typically changed the facts of significant events on several occasions during the psychiatric interview. The examiner found that without corroborating evidence, the Veteran's service records were not consistent with personal trauma and the subsequent development of PTSD symptomatology. Further, not until many years following her separation from service did the Veteran file a claim for service connection for an acquired psychiatric disorder, and/or PTSD. In that regard, the passage of many years between discharge from service and medical documentation of a claimed disability is a factor which tends to weigh against a claim for service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, probative medical evidence also indicates that the Veteran's PTSD symptoms are less likely than not attributable to any in-service experiences. In this regard, the September 2016 VA examiner found that the Veteran did not meet the criteria for a diagnosis of PTSD. Although the Board notes that VA treatment records show a diagnosis of PTSD related to MST, the record does not reflect that treatment clinicians were aware of the Veteran's complete in-service and post-service medical history. Nieves-Rodriguez, supra, at 300 (a physician's knowledge of relevant case facts bears on the probative value assigned to a medical opinion). The Board notes that none of these diagnoses included a specific discussion of the DSM criteria. When faced with conflicting medical opinions, the Board must weigh the credibility and probative value of each of the opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez, supra. Initially, the Board will assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. Here, only the September 2016 VA examiner reviewed the claims file, but review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a veteran. Id. at 303-04. In this case, it does not appear as though the VA treating practitioners had a factually accurate medical history of the Veteran as the service personnel and treatment records failed to support any of the alleged MST incidents as reported by the Veteran. Second, the Board will consider whether or not the medical expert provided a fully articulated opinion. Id. Finally, the Board considers whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez, supra; Stefl, supra. Here, VA treating practitioners did not have access to a factually accurate history, and they also did not provide a fully articulated opinion. In contrast, the September 2016 VA examiner discussed the Veteran's account of the MST; the examiner also provided an analysis of her past and current symptoms in regard to etiology. However, the treating therapists simply attributed PTSD to the alleged MST without further explanation or analysis. See Nieves-Rodriguez, supra; Stefl, supra. For these reasons, the Board finds the opinion of the September 2016 VA examiner more probative than the VA clinical records. Evans, 12 Vet. App. at 30; Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999). Likewise, based on the medical evidence of record, the Board must find that service connection for another acquired psychiatric disorder other than PTSD is also not warranted. In this regard, there is no competent medical evidence linking any current psychiatric disability to service. Again, service treatment records are silent with respect to any findings of an acquired psychiatric disorder. Importantly, after reviewing the claims file, in the highly probative September 2016 VA opinion, the VA examiner concluded that she could not opine with any certainty that the Veteran's maladaptive personality deficits were related to service, and provided a detailed rationale for this opinion. There is no competent evidence of record to refute this opinion. Furthermore, the first post-service evidence of a psychiatric disorder related to service is when the Veteran initially sought treatment in June 2010, approximately 12 years after the Veteran's discharge from service. As noted above, a lengthy period without evidence of treatment may also be viewed as evidence weighing against the Veteran's claim. See generally Maxson, 230 F.3d at 1330. Moreover, although the Veteran has reported experiencing continuing psychiatric symptoms since service, her assertions that her current symptoms are a continuation of the symptoms she experienced since service are outweighed by the more probative September 2016 VA opinion finding no such relation. The Veteran's psychological disorder is not one of those diseases listed at 38 C.F.R. § 3.309(a). Thus, a continuity of symptoms may not be used to establish service connection and a medical nexus is required. See Walker, supra. Moreover, a personality disorder is not an acquired psychiatric disorder for which service connection might potentially be granted under the applicable law and regulations. See 38 C.F.R. § 3.303 (2017). Nevertheless, the Board notes that service connection may be granted, in limited circumstances, for disability due to aggravation of a constitutional or developmental abnormality (to include personality disorder), by superimposed disease or injury. See VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); and VAOPGCPREC 82-90. Again, the September 2016 VA examiner concluded that she could not opine with any certainty that the Veteran's maladaptive personality deficits were related to service. In other words, although the Veteran has been diagnosed with a "separate and distinct" psychiatric disorder that is related to a personality disorder, the examiner clearly found that it was not caused by a superimposed disease or injury that occurred in service. The Board has also considered the Veteran's own statements that she has a current psychiatric disorder related to her military service. The Veteran is competent in this case to provide testimony regarding matters of which she has first-hand knowledge, such as observable symptomatology. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the diagnosis and etiology of a psychiatric disorder that began many years after service and in the context of multiple traumatic events after service, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming the Veteran's lay assertions regarding etiology were competent, the Board nevertheless finds the September 2016 VA examiner's opinion to be more probative, as it is based on a review of the record and the examiner's medical expertise, training, and knowledge. The examiner provided a thorough rationale with a complete discussion of the Veteran's medical history, including her own statements. For the reasons outlined above, the Board concludes that the weight of the evidence is against a finding of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is denied. ____________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs