Citation Nr: 18154117
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 10-47 731
DATE:	November 29, 2018
Entitlement to a rating in excess of 20 percent for degenerative disc disease, L5/S1 is denied. 
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), dissociative identity disorder, and obsessive-compulsive disorder (OCD), is denied.
1. For the entire appeal period, the Veteran’s degenerative disc disease did not result in forward flexion of the thoracolumbar spine to 30 degrees or less; ankylosis of the thoracolumbar or entire spine, intervertebral disc syndrome (IVDS) with incapacitating episodes as defined by VA regulations, or associated objective neurologic abnormalities other than those for which service connection already has been granted.
2. An acquired psychiatric disorder, to include PTSD, dissociative personality disorder, and OCD, is not shown to be causally or etiologically related to any disease, injury, or incident in service and did not manifest within one year of service discharge.
1. The criteria for rating in excess of 20 percent for degenerative disc disease, L5/S1, is denied.  38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5243.
2. The criteria for service connection for an acquired psychiatric disorder have not been met.  38 U.S.C. §§ 101(24), 1101, 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.1(d), 3.6(a), 3.102, 3.303, 3.304, 3.307, 3.309 (2017).
The Veteran had active service from August 1989 to March 1996.  The Veteran is a Peacetime and Gulf War Veteran.
This appeal comes before the Board of Veterans’ Appeals (Board) from rating decisions issued in September 2009 and May 2010 by a Department of Veterans Affairs (VA) Regional Office.  The Board notes the Veteran requested a Board hearing concerning the issues on appeal.  The record shows the Veteran was notified of a scheduled hearing in March 2017; however, there is no indication that such hearing was held.  As a result, the Agency of Original Jurisdiction (AOJ) sent the Veteran a notice letter in April 2018 to clarify whether she still wanted to attend a Board hearing.  The evidence does not show the Veteran responded to the notice letter, and as such, the Board considers the request for a hearing withdrawn.
In May 2017, the Board remanded the claims on appeal for additional development.
Increased Rating
Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity.  Separate diagnostic codes identify the various disabilities.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized.  38 C.F.R. § 4.1.  Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work.  38 C.F.R. § 4.2.  All reasonable doubt will be resolved in the claimant’s favor.  38 C.F.R. § 4.3.  Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating is to be assigned.  38 C.F.R. § 4.7.
Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007).  Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings.  Id. 
The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment.  38 C.F.R. § 4.10. 
Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating.  Otherwise the lower rating will be assigned.  38 C.F.R. § 4.7.  All benefit of the doubt will be resolved in the Veteran’s favor.  38 C.F.R. § 4.3.
The law pertaining to the effective date of a VA claim for increase in disability provides that the effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if any application is received within one year from such date. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o).  If the increase became ascertainable more than one year prior to the date of receipt of the claim, then the proper effective date would be the date of claim.  In a case where the increase became ascertainable after the filing of the claim, then the effective date would be the date of increase.  See generally Harper v. Brown, 10 Vet. App. 125 (1997). 
The record shows VA received an informal, increased rating claim for the Veteran’s degenerative disc disease, L5/S1 (back disability) on October 2, 2009, and therefore, the Board will consider the evidence dated within the one year prior to receipt of the claim. 
Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal exertion, strength, speed, coordination and endurance.  The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled.  See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59.  Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded.  See Mitchell v. Shinseki, 25 Vet. App. 32 (2011).
The factors involved in evaluating and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse.  38 C.F.R. § 4.45. 
In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that for disabilities evaluated on the basis of limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45 pertaining to functional impairment.  The Court instructed that, in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination.  Such inquiry was not to be limited to muscles or nerves.  These determinations were, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. 
The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss.  Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011).  Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment.  Id. 
With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification.  Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased.  Flexion elicits such manifestations.  The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.  38 C.F.R. § 4.59.
The United States Court of Appeals for Veterans Claims (Court) held that “to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of” 38 C.F.R. § 4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016).  Specifically, the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.
When determining the severity of musculoskeletal disabilities, which are at least partly rated on the basis of range of motion, VA must consider the extent of additional functional impairment a veteran may have above and beyond the limitation of motion objectively demonstrated due to pain, limited or excess movement, weakness, incoordination, and premature or excess fatigability, etc., particularly when symptoms “flare up,” to include periods of prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Sharp v. Shulkin, 29 Vet. App. 26, 31-35 (2017); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995).   Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint.   See 38 C.F.R. § 4.59 
For the period on appeal, the Veteran’s back disability has been rated under Diagnostic Code 5243, which pertains to degenerative arthritis of the spine under the General Rating Formula for Diseases and Injuries of the Spine.  Rating determinations under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.  The General Rating Formula provides for a 20 percent rating where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine.  A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine.  Finally, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine.  38 C.F.R. § 4.71a.

Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate Diagnostic Code.
Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees.  Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees.  The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation.  The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees.  The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.
Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2).  Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted.
Note (4): Round each range of motion measurement to the nearest five degrees.
Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.  Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.
Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.  Id.
IVDS may be evaluated under either the General Rating Formula or under the IVDS Rating Formula, whichever method results in the higher evaluation when all disabilities are combined.  See 38 C.F.R. § 4.25 (combined ratings table).
The IVDS Rating Formula provides that a 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months.  A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months.  A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.  Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician.  38 C.F.R. § 4.71a.
The Veteran’s service-connected back disability is rated as 20 percent disabling during the appeal period.  To warrant a higher rating, the medical evidence must show forward flexion of the thoracolumbar spine to 30 degrees or less; ankylosis of the entire thoracolumbar spine or spine; or incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months.  Here, the Board finds evidence of such are not demonstrated at any time during the appeal period.
In January 2011, the Veteran underwent VA examination.  The examiner noted that there was no change in diagnosis.  The examiner described the Veteran’s back disability as showing evidence of radiating pain and positive leg straight raising on both legs, without muscle spasms, atrophy, or ankylosis.  The examiner was unable to perform range of motion testing at that time because the Veteran was unable to stand or tolerate the examinations conducted even while in the wheelchair.  See VA Examination, January 2011. 
Pursuant to the May 2017 Board Remand, the Veteran was afforded additional VA examination in April 2018.  However, the VA examiner again was unable to perform range of motion testing because the Veteran was a fall risk with an unsteady gait and ataxia and was unable to follow the commands.  Similarly, the examiner could not conduct leg raising tests.  There was no evidence of muscle atrophy or ankylosis.  The examiner noted that the “aide thinks the Veteran does not use assistive device at the facility and did not bring any into visit, however came into visit on a stretcher.”  See C&P examination, April 2018.  Moreover, the examiner noted that the Veteran had difficulty communicating due to NSC Huntington’s chorea and schizophrenia.  The Veteran reported that she experienced pain at times.  The VA examiner reported no neurological abnormalities or findings related to the Veteran’s back disability and stated the Veteran did not have IVDS of the thoracolumbar spine.
As VA has made repeated attempts to assess the current nature and severity of the Veteran’s back disability, which have been unsuccessful due to the Veteran’s physical and psychiatric conditions, the Board finds remand for the purpose of a new examination would not assist the Veteran, would serve no useful purpose, and would merely delay a resolution.
As such, the Board must focus the analysis and determination of the issue based on the evidence of record.  Here, the medical evidence does not reflect forward flexion of the thoracolumbar spine to 30 degrees or less; or ankylosis of the entire thoracolumbar spine or entire spine.  The Board has taken into consideration the Veteran’s reported symptoms and finds pertinent her denial of pain on examination in April 2018.  Further, the medical evidence does not indicate the Veteran had any incapacitating episodes during the appeal period due to her service-connected back disability. 
With respect to associated objective neurologic abnormalities, the Veteran is already separately service-connected for bowel dysfunction, bladder dysfunction, and sensory deficits of the left and right lower extremities.  In this regard, the Veteran did not enter a notice of disagreement following the most recent adjudication of such issues.  Furthermore, the Veteran does not contend, nor does the evidence show, that she experiences additional neurological impairment due to her back disability.  Consequently, the Board finds additional, separate ratings are not warranted.
The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran’s disability; however, the Board finds that her symptomatology was stable throughout the period on appeal. Therefore, assigning staged ratings for such disability is not warranted.
Other Rating Considerations
As noted above, the Board has carefully considered the Veteran’s history and symptom reports, including as presented in the medical evidence discussed above, and finds such are contemplated by the disability rating assigned.  Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence when evaluating the pertinent symptoms of the service-connected back disability.  As such, while the Board accepts the Veteran’s testimony concerning the matters she is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluations of functional impairment, symptom severity, and details of clinical features of the service-connected disability.   
Neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, regarding the increased rating claim adjudicated herein.  See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).  
In conclusion, the Board has considered the applicability of the benefit of the doubt doctrine.  Here, however, the preponderance of the evidence is against the Veteran’s claim of entitlement to a rating in excess of 20 percent for service-connected back disability and such must be denied.  
Service Connection
Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C. §§1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  Direct service connection requires evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury.  Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). 
Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include psychoses, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service.  38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309.  According to 38 C.F.R. § 3.384, as applicable in the instant case, the term ‘psychosis’ includes a brief psychotic disorder; delusional disorder; psychotic disorder due to general medical condition; other specified schizophrenia spectrum and other psychotic disorder; schizoaffective disorder; schizophrenia; schizophreniform disorder; and substance/medication-induced psychotic disorder.
Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology.  The United States Court of Appeals for the Federal Circuit clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to “chronic” diseases such as psychoses listed under 38 C.F.R. § 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 
In addition to the general principles governing service connection, to establish entitlement to 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).  A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a).  In this regard, the Board notes that for cases certified to the Board prior to August 4, 2014, as is the case here, the diagnosis of PTSD must be in accordance with the DSM-IV. 
With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304(f), evidence of an in-service stressor, the evidence necessary to establish that the claimed stressor actually varies depending on whether it can be determined that the Veteran “engaged in combat with the enemy.”  See 38 U.S.C. § 1154(b); 38 C.F.R. 3.304(d).  If it is determined through military citation or other supportive evidence that a Veteran engaged in combat with the enemy, and the claimed stressors are related to combat, the Veteran’s lay testimony regarding the reported stressors must be accepted as conclusive evidence as to their actual occurrence and no further development or corroborative evidence will be necessary.  See 38 C.F.R. § 3.304(f). 
Direct service connection for PTSD requires a nexus between a current Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis and a stressor which occurred during service.  38 C.F.R. §§ 3.304 (f), 4.125(a); Cohen v. Brown, 10 Vet. App. 128 (1997).  According to the DSM diagnostic criteria for PSTD, a stressor involves a response including intense fear, helplessness, or horror after experiencing, witnessing, or confronting an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.  Cohen v. Brown, 10 Vet. App.128, 128 (1997).  The sufficiency of a stressor for diagnostic purposes is a medical determination, while the occurrence of a claimed stressor is an adjudicatory determination.  Id.; Moreau v. Brown, 9 Vet. App. 389 (1996).
Moreover, VA recognizes that, because a personal assault is a personal and sensitive issue, many incidents are not officially reported, which in turn creates a proof problem in establishing they did.  It is not unusual for there to be an absence of service records documenting the events the Veteran has alleged.  Therefore, evidence from sources other than service records may corroborate an account of a stressor incident that is predicated on a personal assault.  See, e.g., Patton v. West, 12 Vet. App. 272, 277 (1999).  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 behavior changes following the claimed assault is one type of relevant evidence that may be found in the mentioned 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 may submit any evidence that it received to an appropriate mental health professional for an opinion as to whether it indicates that a personal assault occurred.  Id. 
When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).
The Veteran alleges she has a current acquired psychiatric disorder related to an in-service rape.  She alleges that the person that raped her also raped two other females, but she is unable to provides names for those females.  She states that she told her first sergeant but that he refused to report the rapes.  See Medical Treatment Record, Govt facility, October 2009.  
The record reflects diagnoses of PTSD, dissociative personality disorder, and OCD during the pendency of the appeal, in addition to an indication that she has 20 different personalities.  However, as described in greater detail below, the evidence does not corroborate the Veteran’s reported stressors to support a relationship between service and such diagnoses.
With respect to an in-service diagnosis and/or continuity of psychiatric symptomatology, the Veteran’s service treatment records do not reflect complaints of, treatment for, or a diagnosis of an acquired psychiatric disorder, to include PTSD, dissociative personality disorder, or OCD, despite the Veteran’s assertions of treatment during service.  In addition, the medical evidence indicates the Veteran did not seek VA treatment for an acquired psychiatric disorder until 2009, approximately 13 years following her separation from service.  Although there is an indication that she sought private treatment beforehand, such records were unavailable.  Moreover, the medical evidence dated during the pendency of the appeal indicate the Veteran’s reports of her symptomatology were unreliable based on inconsistency and over-exaggeration.  Furthermore, as described in greater detail below, a VA physician provided a detailed explanation as to why the Veteran’s current diagnoses are not related to an in-service event, injury, or illness.  As a result, the Board finds the competent evidence does not show symptoms of an acquired psychiatric disorder during service or continued symptomatology of such indicating manifestation within one year of service.  
VA Outpatient records dated in June 18, 2009, show the Veteran was being treated for dissociative personality disorder, PTSD, and OCD.  The Board notes the medical treatment records state that physicians diagnosed PTSD and OCD in service; however, as noted above, the service treatment records do not document any such diagnosis.  See Medical treatment records, July 20, 2009.  Outpatient records from June 26, 2009, show the Veteran reported being raped while in the military.  A September 2009 VA treatment record shows a diagnosis of “PTSD related to MST and childhood sexual abuse; OCD; and dissociated identity disorder.
An October 2009 neurological assessment indicates the Veteran contended that she had participated in a covert mission in Korea.  The examiner found that the assessment was not likely an accurate representation of the Veteran’s current level of cognitive and psychological functioning due to the questionable reliability of the obtained test results.  The examiner also found the Veteran’s responses exceeded the threshold for clinical significance.  The examiner further noted that the Veteran reported an uncommon level of anxiety and depressive symptomology that is unusual even in clinical samples.  The examiner found there was little clinical value in the elevated personality profile beyond the notion that the Veteran was clearly attempting to convey the depth of her distress and apparent desire for emotional support and intervention.  See Medical Treatment Record, October 2009.  
A February 2010 letter shows the Veteran’s treating psychiatric found there was no evidence of psychotic illness or organic impairment.
In July 2012, the Veteran was afforded a VA examination.  The examiner noted the current diagnoses of PTSD, disassociate personality disorder, and OCD.  The examiner noted that the Veteran’s reported stressors for PTSD were not related to hostile military or terrorist activity.  Rather, the Veteran reported being raped while stationed at Fort Benjamin, Indiana, in 1991, harassment by drill sergeants, and threats by fellow soldiers.  She stated that she had sought psychiatric treatment in service but would beat men up for harassing her, which resulted in demotion.  Additionally, the examiner noted that the Veteran reported childhood neglect and physical abuse by her mother, and molestation by her maternal uncle and two other male church members.  She also stated that the father of her two older children was abusive and would beat and rape her.  The VA examiner found the Veteran’s stressors of an in-service rape and harassment contributed to her PTSD.  
Medical treatment records note that the Veteran suffers from 20 different personalities and dissociates frequently.  See Medical treatment records, SSA, April 21, 2015.
The Veteran was afforded another VA examination on March 2016.  After conducting a thorough review of the record as well as an in-person examination, the examiner noted the Veteran’s statements were unreliable.  In particular, the Veteran reported being raped in 1991 at Fort Benjamin; however, personnel records indicate that she was stationed at Fort Bennington during that period.  The examiner did note that “the current 2507 Notes documented “vaginal pain, pelvic pain, anal fissure, abdominal pain, Prozac; all markers for military sexual trauma dated 1/01/1992.”  Additionally, the service treatment records document an initial complaint of rectal bleeding in March 1994.  In August 1995, it was noted that she had an IUD with which she had persistent spotting.   A note from September 1995 indicate she complained of chronic pelvic pain, abdominal pain that had started the Monday prior to the meeting, and a history of an irregular menstrual cycle.  
Despite the foregoing, the examiner found there was no evidence in the Veteran’s military personnel records that would indicate evidence of sexual assault.  The examiner found that many of the Veteran’s complaints were very common in women and not necessarily markers for military sexual trauma.  The records also indicate the Veteran was pregnant on two occasions in 1991 with each ending in elective abortions.  While pregnancy could be a marker for military sexual trauma, the examiner noted it was also possible she became pregnant while involved in a consensual sexual relationship.  The examiner found this was particularly relevant in the context of her inaccurate account of the location of the alleged rape.
Furthermore, the examiner noted the Veteran’s military performance did not indicate any reduction in rank or difficulties with fighting and that she was promoted in a timely manner and received several medals.  Due to the Veteran’s history as an unreliable reporter, her reporting that her rape occurred on a base on which she was not stationed at the time of the alleged event, her repeated exaggeration of symptoms in the context of SSDI and neurological evaluations, among others, the examiner concluded it was less likely than not that the alleged military sexual trauma had occurred.  Therefore, any mental health problems would not be attributable to an alleged military sexual trauma.
The Board notes the July 2012 VA examiner’s determination that several reported in-service stressors contributed to the Veteran’s PTSD.  However, this does not clearly demonstrate a causal or etiological nexus between such, and further, the detailed analysis provided by the March 2016 VA examiner indicates the Veteran’s reported stressors were unreliable.  Here, the Board accords great probative weight to the March 2016 VA examiner’s opinion as such considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed.  Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”).  Furthermore, the examiner’s opinion is supported by the remainder of the objective evidence of record.  
Unfortunately, the Board finds the Veteran’s lay reports as to the etiology of her psychiatric disorders lack credibility and therefore deserve little probative value.  The Veteran has reported inconsistent statements pertaining to her stressors, and the service treatment records do not support her reports of in-service treatment.  In addition, the record does not reflect evidence to support her service-related stressors, to include changes in behavior and deterioration of work performance. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the veteran in weighing evidence); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (lack of corroborating contemporaneous evidence may be a factor in determining credibility).  Further, apart from the Veteran’s generalized belief that her disorders are related to service, the record does not contain lay evidence in support of a nexus.  
Finally, in reaching this decision, the Board has considered the doctrine of reasonable doubt.  However, as the preponderance of the evidence is against the Veteran’s claim for entitlement to service connection for an acquired psychiatric disorder, the doctrine is not for application, and the claim must be denied.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Iglesias, Law Clerk 

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