Citation Nr: 0010781 Decision Date: 04/24/00 Archive Date: 05/04/00 DOCKET NO. 97-34 064 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for dysmenorrhea. 2. Entitlement to service connection for tension headaches. 3. Entitlement to service connection for sinusitis. 4. Entitlement to service connection for bursitis of the right deltoid. 5. Entitlement to service connection for a stomach disorder claimed as gastroenteritis. 6. Entitlement to service connection for low back strain. 7. Entitlement to service connection for post-traumatic stress disorder (PTSD). 8. Entitlement to service connection for a bilateral leg condition. 9. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a dysthymic condition claimed as depression with anxiety. 10. Entitlement to an initial compensable evaluation for hemorrhoids. 11. Entitlement to an initial compensable evaluation for allergic dermatitis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. A. Wasik, Associate Counsel INTRODUCTION The veteran served on active duty from August 1976 to February 1979. This matter is before the Board of Veterans' Appeals (Board) on appeal of a September 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The RO granted service connection for hemorrhoids and for allergic dermatitis. Service connection was denied for dysmenorrhea, tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder, a bilateral leg condition, residuals of low back strain and for PTSD. The RO found that new and material evidence had not been submitted to reopen the claim of entitlement to service connection for a dysthymic disorder. Finally, the RO granted a separate 10 percent evaluation based upon multiple, non-compensable, service-connected disabilities under the criteria of 38 C.F.R. § 3.324 (1999). The veteran submitted a notice of disagreement in which she made clear that she was disagreeing with the adjudication by the RO of all the issues covered in the September 1997 rating decision, and advised that she was claiming entitlement to service connection for gout of the left thumb, left foot, and right shoulder. The RO issued a statement of the case addressing all issues with the exception of the denial of service connection for dysmenorrhea and a bilateral leg disorder, and the grants of service connection for hemorrhoids and allergic dermatitis with the assignment of noncompensable evaluations. In October 1997 the RO denied entitlement to service connection for gout of the left thumb and left foot. The RO did not address the claim of service connection for gout of the right shoulder. As this issue has been neither prepared nor certified for appellate review, the Board is referring it to the RO for initial consideration and appropriate action. Godfrey v. Brown, 7 Vet. App. 398 (1995). In her November 1997 substantive appeal the claimant addressed the issues of the denial of entitlement to service connection for tension headaches, sinusitis, a stomach disorder, residuals of low back strain, PTSD, and a dysthymic disorder claimed as depression. The Board has construed a March 1998 conference report from a Decision Review Officer as a timely filed substantive appeal for the claim of entitlement to service connection for bursitis of the right deltoid. The Board notes on a VA Form 9 which was received in November 1997, the veteran indicated she desired a hearing at the RO before a Member of the Board. The Board further notes on a VA Form 9 which was received at the RO in February 1999, the veteran indicated that she did not desire a Board hearing. The Board finds the veteran, via the February 1999 correspondence, has effectively withdrawn her request for a hearing before a member of the Board. The issues of entitlement to service connection for dysmenorrhea and a bilateral leg condition, and entitlement to initial compensable evaluations for hemorrhoids and allergic dermatitis are addressed in the remand portion of this decision. FINDINGS OF FACT 1. The claims of entitlement to service connection for tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and for residuals of low back strain are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation. 2. The claim of entitlement to service connection for PTSD is supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 3. The RO last denied the claim of entitlement to service connection for a dysthymic condition claimed as depression when it issued an unappealed rating decision in November 1994. 4. The evidence submitted since the November 1994 determination does not bear directly and substantially upon the issue at hand, and by itself or in connection with the evidence previously of record, is not so significant that it must be considered in order to fairly decide the merits of the claim. CONCLUSIONS OF LAW 1. The claims for service connection for tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and for residuals of a low back strain are not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for PTSD is well- grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. Evidence submitted since the November 1994 rating decision wherein the RO denied the claim of entitlement to service connection for a dysthymic condition claimed as depression is not new and material, and the veteran's claim for that benefit has not been reopened. 38 U.S.C.A. §§ 5104, 5108, 7105 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.156(a), 20.1103 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection claims Factual Background Review of the service medical records shows intermittent complaints of and treatment for upper respiratory infections and urinary tract infections. In August 1976 the veteran complained of anxiety, insomnia and depression. She was having problems with her husband and child. The assessment was situational reaction. The veteran also sought treatment for pain in the left side of her back in August 1976. She reportedly injured the back lifting weights. The assessment was possible muscular strain. The veteran complained of nasal congestion in August 1976. The assessment was upper respiratory infection. In October 1976, she reported an inability to sleep for long periods of time and also a slight headache. Later in the same month a diagnosis of situational stress was made. She complained of an upset stomach in December 1976. The assessment was gastroenteritis. In January 1977 the veteran reported problems with stomach pains for four days and loose bowel movements. In February 1977, she sought treatment for a stomach ache, diarrhea and a back ache. The assessment was enteritis. In March 1977, she complained of pain in the lower back and stomach for five days. The assessment was urinary tract infection. In April 1977, she complained of nausea, upset stomach and occasional abdominal pain which had been present for three days. The assessment was urinary tract infection and unspecific abdominal pain. A treatment record dated in July 1977 included an assessment of viral syndrome and gastroenteritis. A tension headache was included as an assessment in August 1977. The veteran also sought treatment for pain in the right arm and side which had been present for two days. There was no history of trauma to the neck or shoulders. The assessment was right lateral deltoid bursitis and questionable early bicipital grove tendinitis. In September 1977, the veteran sought treatment several times for back pain. One of the September 1997 treatment records contains the notation that the veteran had been performing heaving lifting. The assessment at that time was low back strain, muscle spasm and questionable etiology for back complaints. Also in September 1977, the veteran complained that her bowels were hard. A September 1977 X-ray examination of the spine revealed minimal curvature which was suggestive of muscle spasm. A separate X-ray examination of the thoracic spine was interpreted as being negative. The veteran was put on profile in September 1977 for back pain. Gastroenteritis was included as an assessment in March 1978. A provisional diagnosis of low back strain was made in June 1978. The veteran reported the pain could have been related to heavy lifting. She received physical therapy for the back pain. At the end of the therapy it was noted that her back was much better with only slight discomfort. Physical examination revealed that all signs and symptoms were within normal limits. Tension headache was included as an assessment in July 1978. The headache was not associated with nausea and vomiting. The veteran did report intermittent spots during the headache. In January 1979 it was noted that the veteran requested a letter in support of a hardship discharge. She was complaining of sleep difficulties. Letters associated with the service medical records dated in January 1979 indicated that she was experiencing insomnia and nervousness due to the pressures of having to care for an eight year old son and a forty day old son. It was recommended that she be separated from service. She declined to undergo a separation examination in February 1979. Records from the veteran's employment at a VA hospital have been associated with the claims files. A medical examination conducted in March 1979 included findings that her eyes, ears, nose and throat, abdomen, extremities, back and neurological and mental health were all normal. The records further document several notifications of traumatic injuries received on the job. In April 1981 she veteran was struck in the abdomen. The veteran was hospitalized at a VA facility from February to June 1981. She was complaining of depression, headaches, sleep problems, excessive eating and difficulties with her ten year old son. The pertinent diagnosis was dysthymic disorder. Private treatment records from Hillcrest Baptist Hospital demonstrate that the veteran was hospitalized in July 1982. She complained, in pertinent part, of headaches. It was noted that she had observed white spots before her eyes in the past. The impression was dizziness and headaches. A second clinical record included the final diagnosis of severe headaches and dizziness probably related to viral illness. The veteran was hospitalized at a VA facility in July 1986. She was complaining of insomnia, nervousness and a history of back problems with a herniated nucleus pulposus. It was noted that the back history dated to an injury in 1983. The pertinent diagnoses were dysthymic disorder and herniated lumbar disc. Lay statements from the veteran's mother, brother, husband, pastor and friends were associated with the claims files in September 1986. The statements attested to symptomatology they observed upon her discharge from active duty. Some of the statements noted a change in her behavior prior to and subsequent to active duty. On VA Form 9 dated in January 1987, the veteran attributed her nervousness during service to problems related to the impending birth of her second child. During a March 1987 RO hearing the veteran testified that her first sergeant informed her it was best to obtain a hardship discharge or else she would end up in jail. She reported that when she first started in service everything went well. She alleged that sometime thereafter, however, everyone turned against her for no apparent reason. She testified that he had headaches thinking about her Air Force career. She testified that she received some sort of counseling in 1977. She reported she began working at the VA hospital in Waco, Texas in April 1983. No medication for nerves had been prescribed to her prior to 1986. She testified as to her belief that the symptoms she was experiencing at the time of the hearing were the same symptoms she had had continuously since active duty. A functional capacity evaluation conducted in November 1987 resulted in a finding that the range of motion of the upper extremity and hand were within normal limits. At the time of the examination the veteran's main complaints were left hand weakness and loss of functional use. A November 1987 disability evaluation was conducted by B. H. B., M.D. The veteran reported that she injured her back on January 6, 1983 when she had fallen to the floor while attempting to restrain a psychiatric patient. She complained of back pain but the examiner noted the pain did not follow any physiologic distribution. Physical examination was conducted and the examiner reported she chose to limit her performance during all phases of testing. She had a normal range of motion of the neck and upper extremities. Her performance on physical testing was "extremely inconsistent." The doctor noted that a Computed Tomography (CT) scan conducted in 1984 revealed a bulging disc in the L4-5 region. It was the doctor's opinion that the veteran's disability and limitation of function were not the residuals of the January 1983 injury but were related to her significant use of medication. She was on long term medication such as Talwin NX and Halcion, which could significantly affect her performance level. The bulging disc noted on the previous CT scan did not represent itself in either her subjective complaints of pain which had no physiologic distribution nor was it related to the limitation of function which she demonstrated. An August 1988 disability evaluation conducted by R. A. G., M.D., has been associated with the claims files. The doctor was asked to evaluate the veteran's back injury. The veteran reported that she was unable to work since her injury because of a jabbing pain in the left hip area and a stinging and biting sensation in her low back area. The doctor opined that her current symptoms and condition were not due to an injury which occurred on January 6, 1983. It was the doctor's opinion that all symptomatology from the January 1983 injury ceased two years post injury. He did not see any evidence of significant musculoskeletal disease or impairment that would keep her from working. It was the doctor's further opinion that due to the length of time she had not been working, rehabilitation to normal working duties was psychologically impossible for her. Private treatment records dated from June 1983 to October 1989 from R. L. S., M.D. included pertinent assessments of lumbar strain and lumbar disc disease. The veteran was complaining of back pain. The doctor noted that lumbar disc disease can occur from kicks. In November 1984, G. N. A., M.D. noted that the veteran had been kicked in the ribs in January 1983. She reported an almost immediate increase in migraine headaches which had been present prior to the injury. In April 1985, the doctor opined that back symptomatology she was reporting at that time was causally related to a work injury in January 1983. VA outpatient treatment records have been associated with the claims files. Outpatient treatment records dated in August 1986 included the notation that the veteran had injured her back at work in 1983. In October 1986, it reported that she had injured her back in an automobile accident. She had a pinched nerve in her hip which radiated to the back. A provisional diagnosis of dysthymic disorder was included on September and December 1986 clinical records. Chronic back pain and continuous depression were included as assessments in July 1987. Dysthymic disorder was included as a diagnosis in January 1988. A March 1989 treatment record included the notation that the veteran had been receiving mental health clinic treatment since her discharge from a hospital in July 1986. She complained of depression, possible auditory hallucinations, irritability and back pain. A separate treatment record dated in March 1989 indicated that she had been having auditory hallucinations. It was opined that the previous diagnosis of dysthymic disorder was clearly in error. The physician found the correct diagnosis was schizo-affective disorder. A June 1989 record included the opinion that she had schizo-affective disorder and had been ill since she was in the service. Schizo-affective disorder was diagnosed in October 1989. She reported she had been hearing voices intermittently since 1979. The diagnosis of schizo-affective disorder was made again in December 1989. She reported experiencing hallucinations, delusions and depression. Rhinitis was assessed in October 1992. In July 1996, anxiety and depression associated with physical problems were included as diagnoses. It was noted that the veteran had a long history of pain due to trauma and many somatic complaints. A separate treatment record dated in July 1996 included the notation that she hurt her back in 1983 and had been unable to work since that time. She also had bad headaches. The pertinent assessments were chronic back pain, chronic recurring headaches and history of psychiatric illness. Chronic recurring headaches, chronic back pain and history of psychiatric illness were noted in October 1996. A separate treatment record dated in October 1996 included the notation that she had been involved in a car accident in September 1996. Since that time, she reported she had had headaches so severe as to cause nausea, vomiting and an inability to get out of bed for three days. It was further noted that the veteran had had sinus problems for three weeks. She reported that she experienced chronic sinus problems at the same time every year. In March 1997, chronic back pain, chronic headaches, history of PTSD, anxiety and depression were diagnosed. In July 1997 it was noted she had been sexually harassed during active duty. The diagnosis at that time was dysthymic disorder with anxiety. A pertinent assessment of chronic low back pain, recurring headaches and PTSD with dysthymia was made in August 1997. In November 1997 she reported that she had difficulties talking of her feelings of sexual harassment while in the military. In January 1998 the veteran reported that she had had chronic back pain since an injury in the 1980's. The assessment was exacerbation of chronic low back pain. A separate treatment record dated in January 1998 included the notation that she had some military sexual harassment experiences. A diagnosis of non-combat related PTSD was made. In January 1998, assessments of allergic rhinitis and sinusitis, migraine headache, chronic low back pain, and PTSD with dysthymic disorder were made. In April 1998 she reported that she had injured her hip during active duty. The pertinent assessments were chronic low back pain, migraine and muscle tension headache, allergic rhinitis and sinusitis and PTSD with dysthymic disorder. In May 1998 the veteran reported that she injured her low back during active duty when lifting sheet metal and post- service she was kicked. She started having headaches during active duty and continued to experience them since that time. She reported that she had had sinusitis and PTSD since entering active duty. The pertinent assessments were chronic low back pain, migraine and muscle tension headache, allergic rhinitis and allergic sinusitis and PTSD with dysthymic disorder. Private treatment records from S. L. M., M.D., a psychiatrist, are of record. In July 1989 the doctor reported that the veteran had injured her back six years prior and had had trouble ever since. It was noted that prior to the injury, she was unrestricted and could do just about anything she wanted to. The doctor conducted a mental status examination. It was his opinion that she had a conversion reaction. The veteran had chronic pain syndrome with secondary depressive features that amounted to major depression as well as generalized anxiety disorder. The diagnoses were chronic severe major depression and generalized anxiety disorder both due to chronic pain from a back problem. In August and September 1991, she complained of frontal headaches and back pain. In August 1992, the doctor reported that he was treating her for chronic pain and elements of moderate to severe, non-psychotic single episode major depression as well as generalized anxiety disorder secondary to the chronic pain. The doctor opined that due to the work injury, she would have difficulty maintaining any type of work. In May 1993 the doctor reported that he had been treating the veteran for sequelae of an on the job injury. In August 1993 the doctor reported that her work injury had increased in symptomatology which also resulted in increased depression. In February 1994 she complained of frequent headaches and pain in her back. In April 1994 she complained of headaches. In June 1994 she complained of left hip pain which would radiate into her back. Sinus headaches were noted in October 1995. Statements from the veteran were received at the RO in March 1997. She described how during active duty co-workers commented on her appearance and made sexually oriented remarks. She reported being pinched on the buttocks at one time. She reported trying to obtain help from a doctor but was informed that most women in the military went through what she was going through. She reported that she was moved from one job to another without reason. She wrote that on another occasion, a technical sergeant attempted to grope her breast. When she informed her first sergeant about what was going on, the first sergeant told her she was depressed and imagining everything. The first sergeant also allegedly informed her that a hardship discharge was in her best interest. After she became pregnant the harassment increased. On a second statement she reported sexual harassment which occurred while she was a VA employee. She wrote that the harassment received at work made her nervous and gave her headaches. She indicated that she failed to describe the harassment she experienced at the time of her RO hearing because she was scared. An April 1997 VA letter shows that the veteran had been accepted for treatment in a PTSD program located in Waco, Texas. Lay statements from the veteran's husband and brother were associated with the claims files in June 1997. The husband wrote that his wife informed him of sexual harassment problems she had during military service. He also described symptomatology he observed. Her brother reported that she had informed him she had been ill treated during active duty. A VA joints examination was conducted in June 1997. The veteran did not remember any subjective complaints regarding her right shoulder. She declined examination of the right shoulder. An X-ray of the right shoulder was interpreted as normal. The diagnosis was history of right shoulder problem of unclear etiology. The examiner was unable to assess the disorder any further due to a lack of cooperation. A VA miscellaneous neurologic disorders examination was conducted in June 1997. The veteran reported that she had had tension headaches but did not remember when they started. She reported the headaches were present almost every day. It was noted that she appeared to have a lack of motivation to participate fully in the examination. She declined participation in some of the physical examination and also evaded or did not answer questions as thoroughly as she could. The examiner noted there appeared to be significant functional overlay in the interactions observed. The diagnosis was headaches apparently related to tension. It was noted that she had tension type headaches while in the service. The report of a June 1997 VA nose and throat examination is of record. The veteran reported she noticed her nose was itchy and eyes were watering with periodic headaches while working in a warehouse in Oklahoma. She took pills every September for sinus symptoms. The diagnosis was seasonal rhinitis. A VA spine examination was conducted in June 1997. The veteran reported she injured her back in 1977 picking up a piece of sheet metal. The examiner noted her back examination and mobility examination were suboptimal at best with significant functional overlay noted as well as lack of effort. There also appeared to be some evasion on her part when it came to performing some of the physical maneuvers. It was also noted that she had red nail polish on all ten of her toes. X-rays revealed mild levoscoliosis and some asymmetry of L4 with a prominent osteophyte from the anterior inferior border of L4. The diagnosis was complaint of back pain. It was noted that she had a history of disc disease related to some kind of injury in 1983. Extensive review of the service records revealed episodes of muscle spasm and back strain, but nothing that would explain her current symptomatology. The veteran underwent a VA stomach examination in June 1997. She could not recall any specific subjective complaints other than sometimes her bowels did not move. The diagnosis was occasional constipation. A VA PTSD examination was conducted in June 1997. The examiner noted the veteran was extremely uncooperative, refusing to answer simple questions. This rendered it impossible to obtain accurate pre-military, active duty or post military history. She refused to provide even a general description of her pre-military life. She complained of irritability, depression and anger. The diagnosis was that the history available in the medical records did not, in the opinion of the examiner, support a diagnosis of PTSD or depression secondary to trauma experienced in the military. No Axis I diagnosis was made. The transcript of a May 1998 RO hearing has been associated with the claims files. The veteran testified that she first started having tension headaches during basic training. She reported the headaches were treated during service with aspirins and rest. She alleged she had the headaches since active duty. She testified that the headaches were present five to six times per week and varied in intensity from mild to migraine. She reported she also saw little specs in her eyes. She testified she first complained of sinusitis and an allergy condition during basic training. The veteran reported she received sinus medicine during active duty. She indicated she took the medicine throughout her military career. She testified she first started having problems with bursitis while working in supply. She reported she experienced pain in the arm and at times could hardly lift the arm. She further reported her arm had bothered her since active duty. She testified she was treated for gastroenteritis from 1976 to 1978. She reportedly experienced pain, gas and a cramp feeling. She reported she did not know when she injured her back. She testified that she had had chronic back pain since active duty up to the present time. With regard to her PTSD claim, she reported that several co-workers made derogatory comments about her. She testified she informed her first sergeant of the situation but he did not do anything. She attributed her anxiety disorder to the harassment she experienced during active duty. She reported she was receiving psychotherapy from Dr. M. at a VA facility. A VA miscellaneous neurological disorders examination was conducted in October 1998. The veteran reported that she was injured on the job while working at a VA hospital in Waco as a nurses assistant. She complained of having headaches for twenty years which prevented her from going to work. She denied nausea and vomiting associated with the headaches. She would see black and clear spots before her eyes during the headaches. The diagnosis was migraine headache. On the report of an October 1998 nose, sinus, larynx and pharynx examination it was recorded that the veteran admitted to symptoms of sinusitis. X-rays of the sinus revealed mucosal thickening of the left maxillary sinus. The diagnosis was sinusitis. The report of an October 1998 VA joints examination has been associated with the claims files. The veteran denied any injury to her right shoulder but did have pain, stiffness, fatigue and lack of endurance. X-rays of the right shoulder were interpreted as normal. The diagnosis was tendonitis of the right shoulder. A VA examination of the large and small intestines was conducted in October 1998. The veteran reported that while on active duty she had an episode of constipation and diarrhea that was treated with medication. A barium swallow examination was normal. An upper gastrointestinal examination was normal. The diagnosis was recurrent constipation/diarrhea secondary to self-medication ingestion with no disease found. The report of an October 1998 examination of the spine has been associated with the claims files. The veteran reported that she injured her back during active duty but did not recall what type of injury it was, when it was or where it was. She also reported that she injured her back in 1983. The examiner did not have access to the veteran's claims files for the examination. X-rays of the lumbar spine revealed possible degenerative joint disease of the L4-L5 disc joint. A CT scan of the lumbar spine was recommended. The diagnosis was chronic lumbar spine strain without evidence of peripheral neuropathy. The examiner opined that the current back condition was probably not related to an injury in-service or related to the intercurrent injury for which she received workman's compensation. A VA PTSD examination was conducted in October 1998. It was noted that the veteran was fully cooperative during the examination and gave complete answers to all questions asked of her. She reported being exposed to continuous and significant sexual harassment during active duty and also one incident of sexual assault in 1976 or 1977. The examiner reported that he could find no evidence to support a diagnosis of PTSD. There was no impairment of thought process or communication, delusions, hallucinations, suicidal or homicidal ideation. Personal hygiene was good as were the other basic activities of daily living. She was well oriented to person, place and time. No significant memory loss was noted. The rate and flow of speech were unremarkable. There was no evidence of panic attacks. There was evidence of depression and depressed mood associated with anxiety as well. She complained of sleep impairment. The examiner did find evidence to support a diagnosis of dysthymia with anxiety. It was noted that the veteran was being treated for dysthymia. The examiner found the degree to which the dysthymic disorder was related to active duty was speculative. The examiner opined that if it could be found that she was treated for anxiety and/or depression while in the military, this treatment would support her claim of sexual harassment and a sexual assault. The examiner further noted the service history was significantly involved in her current symptomatology. The examiner was unable to find documentation of her being treated for anxiety and/or depression during active duty. The diagnosis was dysthymic disorder. Service Connection Criteria In order to be entitled to service connection for a disease or disability, the evidence must reflect that a disease or disability was either incurred in or aggravated by military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). That an injury occurred in service alone is not enough; there must be current disability resulting from that condition or injury. If there is no showing of a chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after service 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). The threshold question that must be resolved with regard to a claim is whether the veteran has presented evidence of well- grounded claims. See 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. See Murphy, 1 Vet. App. at 81. An allegation of a disorder that is service connected is not sufficient; the veteran must submit evidence in support of a claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden of necessity will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). In order to obtain service connection, there must be both evidence of a disease or injury that was incurred in or aggravated by service, and a present disability which is attributable to such disease or injury. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. A claim for service-connection for a disability must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); see also Brammer v. Derwinski, 3 .Vet. App. 223, 225 (1992) (absent proof of a present disability there can be no valid claim). Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lay assertions of medical causation cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Id. Under the provisions for direct service connection for PTSD, 60 Fed. Reg. 32807-32808 (1999) (codified at 38 C.F.R. § 3.304(f)), service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (diagnosis of mental disorder); 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. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to this combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). The VA regulation was changed in June 1999 to conform to the Court's determination in Cohen v. Brown, 10 Vet. App. 128 (1997). As the Cohen determination was in effect when the RO last reviewed this case, the Board finds no prejudice to the veteran in proceeding with this case at this time. See Bernard v. Brown, 4 Vet. App. 384 (1993). Where a veteran served continuously for 90 days or more and arthritis, psychosis or peptic ulcer becomes manifest 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 in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Tension Headaches The Board finds the claim of entitlement to service connection for tension headaches to be not well-grounded as there is no competent evidence of record demonstrating the existence of tension headaches which have been linked to active duty. During active duty, the veteran complained of headaches in October 1976 and tension headaches were diagnosed in August 1977 and July 1978. There were no further complaints of headaches during the last six months of active duty. No separation examination was conducted. However, an employment examination was conducted in March 1979 at which time there were no pertinent complaints or diagnosis noted. The next evidence of record of a complaint of a headache was included on the report of a hospitalization at a VA facility in June 1981. The veteran reported having headaches at that time but no diagnosis was made. Headaches were again noted on a private hospitalization report dated in July 1982 but the headaches were attributed to a viral illness. A June 1997 VA miscellaneous neurological evaluation resulted in a diagnosis of headaches apparently related to tension. The examiner further noted that the veteran had tension type headaches during active duty. The most recent VA neurological examination resulted in a diagnosis of migraine headaches. The veteran has testified to the fact that she has had headaches continuously since active duty. The Board finds the veteran is competent to report on the frequency of the headaches she experiences. She is not competent, however, to attribute that symptomatology to active duty. Nor is the veteran competent to diagnose what type of headache she experienced. Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Symptoms, and not necessarily treatment, are the essence of any evidence of such continuity. Id. at 496. The Court has held in Savage v. Gober, 10 Vet. App. 488 (1997), that the "continuity of symptomatology" provision of 38 C.F.R. § 3.303(b) may obviate the need for medical evidence of a nexus between present disability and service. See Savage, 10 Vet. App. at 497. The only proviso is that there be medical evidence on file demonstrating a relationship between the veteran's current disability and her post-service symptomatology, unless such a relationship is one as to which a lay person's observation is competent. The Board notes the examiner who conducted the June 1997 neurological examination diagnosed the veteran's headaches as tension headaches. The examiner also noted that the veteran was treated for tension headaches during active duty. Despite this notation, the examiner did not link the tension headache he diagnosed to active duty. The examiner also did not link the headache symptomatology the veteran alleged was present from active duty to the present to the current diagnosis of tension headache. The Board notes at the time of the most recent VA neurological evaluation, a diagnosis of migraine headache was made. The examiner did not relate the migraine headache to active duty. There is no evidence of record demonstrating that the veteran had migraine headaches during active duty. The examiner did not link the veteran's allegations of continuous headache symptomatology and his current diagnosis of migraine headache to active duty. As there is no competent evidence of record which links currently diagnosed tension headaches to active duty, the claim of entitlement to service connection for tension headaches must be denied as not well-grounded. The Board notes the veteran performed duties as a nurses assistant and thus has some medical training. The Board finds, however, that the veteran is a lay person. There is no evidence of record showing, nor has the veteran claimed that she received, specialized training sufficient to qualify her as competent to make a medical diagnosis or to relate a medical disorder to a specific cause. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Sinusitis The Board finds the claim of entitlement to service connection for sinusitis to be not well-grounded. While the veteran was treated during active duty for upper respiratory infections and also reported symptomatology related to the sinuses, sinusitis was not included in any of the service medical records. At the time of the employment examination conducted in March 1979, the veteran's nose was determined to be normal. The first competent evidence of record of a diagnosis of sinusitis was included in a VA outpatient treatment record dated in January 1998. Sinusitis was again diagnosed in April 1998 and May 1998 as evidenced by the VA outpatient treatment records. None of the records which included diagnoses of sinusitis linked the disorder to active duty. The October 1998 VA examination resulted in a diagnosis of sinusitis but the disorder was not linked to active duty. The veteran has testified that she has had sinusitis since active duty. The veteran is competent to provide evidence as to symptomatology related to her sinuses. The Board finds, however, the veteran is not competent to diagnose the disorder or to link it to active duty. There is no competent evidence of record linking sinusitis to active duty nor is there competent evidence of record demonstrating a relationship between the veteran's current disability and her post-service symptomatology and such a relationship is not one as to which a lay person's observation is competent. As there is no competent evidence of record showing the veteran had sinusitis during active duty and as there is no competent evidence of record linking the currently diagnosed sinusitis to active duty, the claim of entitlement to service connection for sinusitis must be denied as not well-grounded. Bursitis of the right deltoid Analysis The Board finds the claim of entitlement to service connection for bursitis of the right deltoid is not well- grounded as there is no evidence of the current existence of bursitis of the right deltoid. Right lateral deltoid bursitis and questionable early bicipital grove tendinitis were assessed one time during active duty in August 1977. No further assessments or diagnosis of the disorders were included in the service medical records. The veteran's back and extremities were noted to be normal on the report of a post-service employment examination conducted in March 1979. A functional capacity evaluation conducted in November 1987 revealed that the range of motion of the veteran's upper extremity and hand were within normal limits. The next evidence of record of any complaints of, diagnosis of or treatment for a right shoulder disorder was included on the report of a June 1997 VA joints examination. At that time, the veteran reported that she did not remember any specific complaints regarding her right shoulder. The diagnosis was history of right shoulder problem of unclear etiology. The Board notes that tendonitis of the right shoulder was found to be present at the time of the most recent VA examination. The disorder was not, however, linked to active duty. The in-service notation of early bicipital groove tendonitis was not an actual diagnosis of the disorder but was qualified by a question mark on the clinical record. The only competent evidence of record of a current right shoulder disorder was included on the report of an October 1998 VA joints examination. The diagnosis at that time was tendonitis of the right shoulder. The disorder was not linked to active duty by the examiner. The veteran testified in May 1998 that she started having problems with bursitis during active duty which was reflected by right arm pain. She further testified that she had had right arm pain since active duty. However, there is no competent evidence of record demonstrating a relationship between the veteran's current right shoulder disability and her post-service symptomatology and such a relationship is not one as to which a lay person's observation is competent. As there is no competent evidence of record linking a current shoulder disorder to active duty, the claim of entitlement to service connection for bursitis of the right shoulder must be denied as not well-grounded. Stomach disorder claimed as gastroenteritis The Board finds the claim of entitlement to service connection for a stomach disorder claimed as gastroenteritis to be not well-grounded as there is no evidence of a current disability which has been linked to active duty. The veteran was treated several times during active duty for stomach problems diagnosed as gastroenteritis, enteritis and unspecific abdominal pain. However, there is no post-service evidence of record of any chronic stomach disorders which has been linked to active duty. The VA stomach examination conducted in June 1997 diagnosed occasional constipation. The constipation was not linked to active duty. The VA examination of the large and small intestines conducted in October 1998 found no evidence of a stomach disease. The examiner opined that the veteran's recurrent constipation and diarrhea were the result of self- medication. As there is no evidence of record of a current gastrointestinal disability which has been linked to active duty by competent evidence, the claim of entitlement to service connection for a stomach disorder claimed as gastroenteritis must be denied as not well-grounded. Low back strain The Board finds the claim of entitlement to service connection for residuals of a low back strain to be not well- grounded. The veteran was treated several times during active duty for back symptomatology beginning in August 1976. In-service diagnoses and impressions of the back symptomatology were muscular strain, low back strain and muscle spasm. Low back strain was included as a provisional diagnosis in June 1978. Following the June 1978 provisional diagnosis, the veteran underwent physical therapy for the back pain. At the end of the physical therapy, the veteran reported her back was much better with only mild discomfort. Physical examination revealed all signs and symptoms were within normal limits. X-rays of the back taken during active duty were interpreted as being negative. A back disorder was not noted at the time of the veteran's employment examination which was conducted in March 1979. Numerous clinical records associated with the claims files evidence the fact that the veteran reported while seeking medical treatment that she injured her back while working in 1983. The claims files also include several opinions from medical professionals as to the etiology of the veteran's back condition. None of these opinions links the back condition to any incident of active duty. In November 1987, B. H. B., M.D. opined that the veteran's current back symptomatology was not the result of the 1983 injury but was the result of the significant use of medication. In August 1988, R. A. G., M.D. opined that the veteran's back symptomatology at that time was not the result of a 1983 injury as all symptomatology from the 1983 injury had ceased two years post-injury. The report of the June 1997 VA spine examination, which was based on a review of the service medical records, did not link the veteran's current back symptomatology to any incident of active duty. Finally, the examiner who conducted the October 1998 VA spine examination opined that the veteran's current back condition was probably not related to an injury in-service or to the post-service on the job injury. The Board finds that all the competent evidence of record demonstrates that the veteran's current back condition was not related to any incident of active duty. The Board notes the veteran testified that she had had continuous problems with her back since active duty. While the veteran is competent to report on the presence and duration of her back symptomatology, she cannot, diagnose a back disorder or link the disorder to active duty. There is no competent evidence of record demonstrating a relationship between the veteran's current back disability and her post- service symptomatology and such a relationship is not one as to which a lay person's observation is competent. The Board notes the vast majority of the veteran's recorded comments as to the history of her back condition included in clinical records attributes her back condition to a post- service injury which occurred in 1983. The veteran's claims that she has tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and residuals of a low back strain are predicated upon her own unsubstantiated opinions. As it is the province of trained health care professionals to enter conclusions which require medical opinions as to causation, Grivois, the veteran's lay opinions are an insufficient basis upon which to find these claims well grounded. Espiritu, King. Accordingly, as well grounded claims must be supported by evidence, not merely allegations, Tirpak, the veteran's claims for service connection for tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and residuals of a low back strain must be denied as not well grounded. The Board finds that the RO advised the appellant of the evidence necessary to establish well grounded claims, and the appellant has not indicated the existence of any post service medical evidence that has not already been obtained that would well ground her claims. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F. 3d. 1464 (Fed. Cir. 1997). As the veteran has not submitted well grounded claims for service connection for tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and residuals of a low back strain, the doctrine of reasonable doubt has no application. The Court has held that if the appellant fails to submit a well grounded claim, VA is under no duty to assist in any further development of the claim. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); 38 C.F.R. § 3.159(a) (1999). The appellant's representative contends that subsequent to the Court's decisions pertaining to this issue, VA expanded its duty to assist the appellant in developing evidence to include the situation in which the appellant has not submitted a well grounded claim. Veterans Benefits Administration Manual M21-1, Part III, Chapter I, 1.03(a), and Part VI, Chapter 2, 2.10(f) (1996). The appellant's representative further contends that the M21- 1 provisions indicate that the claims must be fully developed prior to determining whether the claims are well grounded, and that this requirement is binding on the Board. The Board, however, is required to follow the precedent opinions of the Court. 38 U.S.C.A. § 7269 (West 1991); Tobler v. Derwinski, 2 Vet. App. 8, 14 (1991). Subsequent to the revisions to the M21-1 Manual, in Meyer v. Brown, 9 Vet. App. 425 (1996), the Court held that the Board is not required to remand a claim for additional development, in accordance with 38 C.F.R. § 19.9 (1999), prior to determining that a claim is not well grounded. The Board is not bound by an administrative issuance that is in conflict with binding judicial decisions, and the Court's holdings on the issue of VA's duty to assist in connection with the well grounded claim determination are quite clear. Bernard v. Brown, 4 Vet. App. 384, 394 (1993); 38 C.F.R. § 19.5 (1999). In Morton v. West, 12 Vet App 477 (1999), the Court held that the Manual M21-1 provisions pertaining to the development of claims prior to a finding of well groundedness are interpretative, in that they do not relate to whether a benefit will be allowed or denied, nor do they impinge on a benefit or right provided by statute or regulation. The Court found that the Manual M21-1 provisions constituted "administrative directions to the field containing guidance as to the procedures to be used in the adjudication process," and that the policy declarations did not create enforceable rights. The Court also found that interpretative provisions that are contrary to statutes are not entitled to deference, and that in the absence of a well grounded claim, VA could not undertake to assist a veteran in developing the facts pertinent to the claim. The Board has determined, therefore, in the absence of well grounded claims for service connection for tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and residuals of a low back strain, VA has no duty to assist the veteran in developing her case. PTSD The Board finds the claim of entitlement to service connection for PTSD to be well grounded. In this case, the veteran claims to have PTSD as a result of in-service personal assaults. The veteran's testimony with respect to her in-service stressors must be accepted as true for the purpose of determining whether the claim is well grounded. See King v. Brown, 5 Vet. App. 19, 21 (1993). Associated with the claims file are several VA outpatient treatment records which include diagnoses of PTSD including one record dated in January 1998 which diagnosed non-combat related PTSD. It was noted on the January 1998 clinical record that the veteran had "some military sexual harassment experiences." This also must be presumed to be credible for the limited purpose of establishing whether the claim of entitlement to service connection for PTSD is well grounded. The Board finds such a diagnosis sufficient to find the claim of entitlement to service connection for PTSD to be well- grounded. The January 1998 clinical record provides a diagnosis of PTSD and a tentative link to active duty by it's reference to in-service sexual harassment experiences. No other stressors were included on the January 1998 record. The Board finds, however, that the issue of entitlement to service connection for PTSD must be remanded for additional development which is addressed in the remand portion of this decision. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a dysthymic condition claimed as depression. Factual Background The evidence which was of record at the time of the November 1994 rating decision wherein the RO declined to reopen the claim of entitlement to service connection for a nervous disorder is set out below. Review of the service medical records shows that in August 1976 the veteran complained of anxiety, insomnia and depression. She was having problems with her husband and child. The assessment was situational reaction. In October 1976 a diagnosis of situational stress was made. In January 1978 she was seen at the mental health clinic for personal problems. In January 1979 it was noted that the veteran requested a letter in support of a hardship discharge. She was complaining of sleep difficulties. Letters associated with the service medical records dated in January 1979 indicated that she was experiencing insomnia and nervousness due to the pressures of having to care for an eight year old son and a forty day old son. It was recommended that she be separated from service. She declined to undergo a separation examination in February 1979. A March 1979 report of an examination for employment at a VA facility is of record. The veteran's mental health at that time was determined to be normal. The veteran was hospitalized at a VA facility from February 1981 to June 1981. She complained of depression, headaches, sleep problems, excessive eating and difficulties with her son. The Axis I diagnosis was dysthymic disorder. Service connection was originally denied for a nervous condition in July 1981. The RO noted that dysthymic disorder was first diagnosed years after the veteran's discharge from service. She was informed of the decision and of her procedural and appellate rights via correspondence dated in July 1981. She did not appeal the decision which became final in July 1982. The veteran was hospitalized at a VA facility in July 1986. She was complaining of insomnia and nervousness. The pertinent diagnosis was dysthymic disorder. Lay statements were associated with the claims file in September 1986. Some of the statements attested to the fact that the veteran changed after serving on active duty. The transcript of a March 1987 RO hearing is of record. The veteran testified that she had feelings of hostility, insomnia, nervousness and depression during service. She reported that she had psychiatric counseling in 1977 and psychiatric testing in 1978. She alleged she was forced to accept a hardship discharge or else she would have been dishonorably discharged. She indicated that her mental disorder had not improved and she felt the same way she did when she was in the service. Her husband testified that after her discharge from active duty, she would go off into deep depressions and fly into rages. In January 1988, the Board affirmed the denial of service connection for a nervous disorder. The Board found that a chronic nervous disorder, diagnosed as dysthymic disorder, was not present during military service. VA outpatient treatment records have been associated with the claims files. Dysthymic disorder was noted in January 1988. In January 1989, an examiner noted the veteran was schizo- affective and had been ill since active duty. In March 1989, a diagnosis of schizo-affective disorder was made. The examiner opined at that time that the previous diagnosis of dysthymic disorder was clearly in error. Private treatment records from S. L. M., M.D. are of record. The records demonstrate the veteran was receiving medication for depression. By rating decision dated in November 1994, the RO found that new and material evidence had not been submitted to reopen the claim of entitlement to service connection for a nervous disorder. The RO noted there was no evidence of treatment for a nervous disorder during active duty nor was a medical opinion associated with the claims files which related a nervous disorder to active duty. The evidence added to the record subsequent to the November 1994 rating decision wherein the RO found new and material evidence had not been submitted to reopen the claim of entitlement to service connection for a nervous condition is set out below. Additional VA outpatient treatment records have been associated with the claims files. The records include notations to the effect that the veteran had variously diagnosed mental disorders including dysthymic disorder, PTSD and schizoaffective disorder. Lay statements from the veteran's husband and brother attested to changes they noted in her. Additional private treatment records from S. L. M., M.D., have been associated with the claims files. In July 1989 the physician opined that the veteran did not have a conversion reaction. He opined that she had major depression and generalized anxiety disorder, both of which were due to chronic pain from a back condition. The report of a June 1997 VA PTSD examination has been associated with the claims files. The examiner noted the veteran was extremely uncooperative, refusing to answer simple questions. It was the examiner's opinion that her medical records did not support a diagnosis of PTSD or depression secondary to trauma experienced in the military. No Axis I diagnosis was made. The transcript of a May 1998 local RO hearing is of record. The veteran attributed her anxiety disorder to harassment she experienced during active duty. The report of an October 1998 VA PTSD examination is of record. The examiner found no evidence of record to support a diagnosis of PTSD. The examiner did find evidence to support a diagnosis of dysthymia with anxiety. He further noted that the degree to which the dysthymic disorder was related to service was speculative. He opined that if it could be found that the veteran was treated for anxiety and/or depression while in the military, this treatment would support her claim of sexual harassment and sexual assault. The veteran's service history was significantly involved in her current symptomatology. The examiner was unable to find documentation of the veteran being treated for anxiety or depression during active duty. Criteria In order to obtain service connection, there must be both evidence of a disease or injury that was incurred in or aggravated by service, and a present disability which is attributable to such disease or injury. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). If no notice of disagreement is filed within the prescribed period, the action or determination shall become final and the claim will not thereafter be reopened or allowed, except as otherwise provided by regulation. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. § 20.1103 (1999). A decision of a duly constituted rating agency or other agency of original jurisdiction shall be final and binding on all field offices of the Department of Veterans Affairs as to conclusions based on the evidence on file at the time VA issues written notification in accordance with 38 U.S.C.A. § 5104. (West 1991). A final and binding agency decision shall not be subject to revision on the same factual basis except by duly constituted appellate authorities or except as provided in § 3.105 of this part. 38 C.F.R. § 3.104(a). The Board does not have jurisdiction to consider a previously adjudicated claim unless new and material evidence is presented. Barnett v. Brown, 83 F.3d 1380, 1384 (Fed. Cir. 1996). When new and material evidence has not been submitted in a previously denied claim "[f]urther analysis...is neither required, nor permitted." Butler v. Brown, 9 Vet. App. 167, 171 (1996) (finding in a case where new and material evidence had not been submitted that the Board's analysis of whether the claims were well grounded constituted a legal nullity). Thus, the well groundedness requirement does not apply with regard to reopening disallowed claims and revising prior final determinations. Jones v. Brown, 7 Vet. App. 134 (1994). The regulations define new and material evidence as follows: New and material evidence means evidence not previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999). New evidence is evidence which (1) was not in the record at the time of the final disallowance of the claim, and (2) is not merely cumulative of other evidence in the record. Smith v. West, 12 Vet. App. 312 (1999); Evans v. Brown, 9 Vet. App. 273, 283 (1996). New evidence is considered to be material where such evidence provides a more complete picture of the circumstances surrounding the origin of the veteran's injury or disability, even where it will not eventually convince the Board to alter its decision. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). The Board notes that the U.S. Court of Appeals for the Federal Circuit recently ruled that the Court erred in adopting the test articulated in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). In Colvin, the Court adopted the following rule with respect to the evidence that would justify reopening a claim on the basis of new and material evidence, "there must be a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome." Colvin, 1 Vet. App. at 174. In light of the holding in Hodge, the Board will analyze the evidence submitted in the case at hand according to the standard articulated in 38 C.F.R. § 3.156(a). The Court has clarified that, with respect to the issue of materiality, the newly presented evidence need not be probative of all the elements required to award the claim as in this case dealing with claims for service connection. Evans v. Brown, 9 Vet. App. 273, 284, (1996) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996) (table)). Rather, it is the specified bases for the final disallowance that must be considered in determining whether the newly submitted evidence is probative. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). With regard to petitions to reopen previously and finally denied claims, the Board must conduct a three-step analysis. Elkins v. West, 12 Vet. App. 209 (1999); Winters v. West, 12 Vet. App. 203 (1999). First, the Board must determine whether the evidence presented or secured since the prior final denial of the claim is "new and material." Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). If new and material evidence is presented or secured with respect to a claim that has been finally denied, the claim will be reopened, and the Board will determine, based on all the evidence of record in support of the claim, and presuming the credibility thereof, whether the claim is well-grounded pursuant to 38 U.S.C.A. § 5107(a). If the claim is well-grounded, the case will be decided on the merits, but only after the Board has determined that VA's duty to assist under 38 U.S.C.A. § 5107 has been fulfilled. The Court noted in Elkins and Winters that by the ruling in Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998), the Federal Circuit Court "effectively decoupled" the determinations of new and material evidence and well-groundedness. Thus, if the Board determines that additionally submitted evidence is "new and material," it must reopen the claim and perform the second and third steps in the three-step analysis, evaluating the claim for well-groundedness in view of all the evidence, both new and old, and, if appropriate, evaluating the claim on the merits. See Elkins, 12 Vet. App. 209 (1999) and Winters v. West, 12 Vet. App. 203 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 3.102, 4.3 (1999). Analysis The appellant seeks to reopen her claim of entitlement to service connection for a dysthymic condition claimed as depression. When a claim is finally denied by the RO, the claim may not thereafter be reopened and allowed, unless new and material evidence has been presented. 38 U.S.C.A. § 7105; 38 C.F.R. § 3.104. When an appellant seeks to reopen a finally denied claim, the Board must review all of the evidence submitted since that action to determine whether the claim should be reopened and readjudicated on a de novo basis. Glynn v. Brown, 6 Vet. App. 523, 529 (1994). In order to reopen a finally denied claim there must be new and material evidence presented since the claim was last finally disallowed on any basis, not only since the claim was last denied on the merits. Evans v. Brown, 9 Vet. App. 273 (1996). Under Evans, evidence is new if not only previously of record and is not merely cumulative of evidence previously of record. The Board finds new and material evidence has not been submitted to reopen the claim of entitlement to service connection for a dysthymic condition claimed as depression. The claim was last denied in November 1994 at which time the RO noted there was no evidence of treatment for a nervous disorder during active duty nor was a medical opinion associated with the claims files which related a nervous disorder to active duty. The VA outpatient treatment records associated with the claims files subsequent to the November 1994 rating decision which are not duplicates of evidence previously considered are new but not material. None of these clinical records links a dysthymic condition to active duty. The lay statements from the veteran's brother and husband are new but not material. The brother and husband are competent to report on symptomatology they observe in the veteran but are not competent to diagnose a mental disorder or to determine the etiology of any mental disorder. The statements have no probative value as far as they attempt to link a mental disorder to active duty. The private treatment records from S. L. M., M.D., are new but not material. The physician found that the veteran had major depression and generalized anxiety disorder but he attributed the disorder to chronic pain from a back condition. The veteran is not service-connected for a back condition. As this evidence does not link a current dysthymic condition to active duty, it is not material. The report of the June 1997 VA PTSD examination is new but not material. The report does not provide competent evidence of the current existence of a dysthymic condition which has been linked to active duty. The evidence actually reinforces the denial of service connection for a dysthymic condition as the examiner provided a competent opinion to the effect that the veteran did not have depression as a result of trauma she experienced during active duty. The transcript of the May 1998 RO hearing is new but not material. The veteran testified that her anxiety disorder was the result of sexual harassment she experienced during active duty. The veteran is competent to report she experienced sexual harassment during active duty, but is not competent to diagnose a mental disorder or to determine the etiology of the mental disorder. The Board notes the veteran performed duties as a nurse. However, there is no evidence of record and the veteran has not alleged that she received specialized training which would make her competent to diagnose a mental disorder or to determine the etiology of the mental disorder. As such, the veteran's testimony as to the etiology of her mental disorder is without probative weight and is not material to her claim. The report of an October 1998 VA PTSD examination is new but not material. The examination report included a competent opinion to the effect that the veteran had dysthymic disorder and anxiety which was linked to active duty provided there was evidence that the veteran was treated for anxiety and/or depression during active duty. However, the examiner noted that he was unable to find any evidence of the veteran's being treated for dysthymia or anxiety during active duty. The examiner also noted such an opinion was speculative. The Board finds this evidence is not material as it does not link a current dysthymic condition to active duty. While the examiner noted there might be a link, he further reported he was unable to find evidence to link the dysthymia to active duty. The Court has held that medical opinions expressed in speculative terms cannot establish a plausible claim; service connection may not be based on resort to speculation or remote possibility. See 38 C.F.R. § 3.102 (1998); see also Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Bostain v. West, 11 Vet. Appellant. 124, 127 (1998). The veteran has not submitted additional evidence which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of this claim. As the Board noted earlier, the Court announced a three step test with respect to new and material cases. Under the new Elkins, test, VA must first determine whether the veteran has submitted new and material evidence under § 3.156 to reopen the claim; and if so, VA must determine whether the claim is well grounded based upon a review of all the evidence of record; and lastly, if the claim is well grounded, VA must proceed to evaluate the merits of the claim but only after ensuring that the duty to assist has been fulfilled. Winters v. West, 12 Vet. App. 203, 206 (1999); Elkins v. West, 12 Vet. App. 209, 218-19 (1999). As new and material evidence has not been submitted to reopen the veteran's claim for service connection for a dysthymic condition claimed as depression, the first element has not been met. Accordingly, the Board's analysis must end here. Butler, 9 Vet. App. at 171. ORDER The veteran not having submitted well grounded claims of entitlement to service connection for tension headaches, sinusitis, bursitis of the right deltoid, a stomach disorder claimed as gastroenteritis, and residuals of a low back strain, the appeals are denied. The claim of entitlement to service connection for PTSD is well grounded. The veteran not having submitted new and material evidence to reopen the claim of entitlement to service connection for a dysthymic condition claimed as depression, the appeal is denied. REMAND The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. Service connection for dysmenorrhea and a bilateral leg condition, and initial compensable evaluations for hemorrhoids and allergic dermatitis. Review of the claims file discloses that in September 1997 the RO, in pertinent part, denied the claims of entitlement to service connection for dysmenorrhea and a bilateral leg condition. The RO also granted service connection for hemorrhoids and allergic dermatitis with assignment of noncompensable evaluations. The veteran was informed of the decision the same month. She submitted a timely notice of disagreement with all issues adjudicated by the RO in the September 1997 rating decision. The statement of the case did not include the above issues. When there has been an initial RO adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitled to a statement of the case, and the RO's failure to issue a statement of the case is a procedural defect requiring remand. Godfrey v. Brown, 7 Vet. App. At 408-10 (1995); Archbold v. Brown, 9 Vet. App. 124 (1996); Manlincon v. West, 12 Vet. App. 238 (1999). Service Connection for PTSD. Since the veteran's claim of entitlement to service connection for PTSD has been found to be well grounded, VA's statutory duty to assist attaches. 38 U.S.C.A. § 5107 (West 1991). As reported above, under the provisions for direct service connection for PTSD, 60 Fed. Reg. 32807-32808 (1999) (codified at 38 C.F.R. § 3.304(f)), service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (diagnosis of mental disorder); 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. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to this combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). In this case, as there is no evidence that the veteran was engaged in combat with the enemy or that the claimed stressor is related to such combat, there must be corroborative evidence of the claimed in-service stressors. See Zarycki v. Brown, 6 Vet. App. 91 (1993). While the claims file includes diagnoses of PTSD, these diagnoses of PTSD were based upon reported in-service stressors that have not been verified. Verification of the veteran's aforementioned reported in-service stressors is necessary. The existence of an event alleged as a "stressor" that results in PTSD, though not the adequacy of the alleged event to cause PTSD, is an adjudicative, not a medical determination. See Zarycki, supra. The sufficiency of the stressor is a medical determination and adjudicators may not render a determination on this point in the absence of independent medical evidence. See West; Colvin v. Derwinski, 1 Vet. App. 171 (1991). As discussed above, the presumption of credibility in King applies only to the matter of the well groundedness of the claim. Once all of the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In so doing, the Board has a duty to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997) and cases cited therein. It is noted that victims of in-service personal assault may find it difficult to produce evidence to support the occurrence of the stressor. However, alternate sources are available that may provide credible support to a claim of an in-service personal assault. These include medical or counseling treatment records following the incident, military or civilian police reports, reports from crisis intervention or other emergency centers, statements from confidants such as family members, roommates, clergy, or fellow service members, or copies of personal diaries or journals. VA Adjudication Manual M21-1 (M21-1), Part III, 5.14(c) (February 20, 1996). The Court has held that the provisions in M21-1, Part III, 5.14(c), which address PTSD claims based on personal assault are substantive rules which are the equivalent of VA regulations. Cohen; YR v. West, 11 Vet. App. 393, 398-99 (1998); Patton v. West, 12 Vet App 272 (1999). The Board finds the RO did not comply with one of the development requirements from M21-1, Part III, 5.14(c) by not sending the veteran stressor development letters specifically tailored for personal assault cases. The Board further finds that the RO did not comply with the provisions in M21-1, Part III, 5.14(c) regarding behavior changes. Behavior changes that occurred at the time of the incident may indicate the occurrence of an in-service stressor based on personal assault. The RO must determine whether the veteran exhibited behavior changes in service. See M21-1, Part III, 5.14(c)(8). If there is evidence of behavior changes, it should be determined whether these indicate the occurrence of a stressor. Secondary evidence may need interpretation by a clinician, particularly if it involves behavior changes, and evidence that documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician. M21-1, Part III, 5.14(c)(9); Patton. To ensure that VA has met its duty to assist the veteran in developing the facts pertinent to her claims and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should request the veteran to identify the names, addresses, and approximate dates of treatment for all health care providers, VA and non-VA, inpatient and outpatient, who may possess additional records pertinent to her claims of entitlement to service connection for dysmenorrhea and a bilateral leg condition and PTSD, and initial compensable evaluations for hemorrhoids and allergic dermatitis. With reference to the PTSD claim, the veteran is advised that this information is necessary to obtain supportive evidence of the stressful events and that she must be as specific as possible because without such details an adequate search for verifying information can not be conducted. After obtaining any necessary authorization or medical releases, the RO should then request any supporting evidence from alternative sources identified by the veteran and any additional alternative sources deemed appropriate, if she has provided sufficiently detailed information to make such request feasible. The RO should request and associate with the claims file legible copies of the veteran's complete treatment reports from all sources identified whose records have not previously been secured. Regardless of the response from the veteran, the RO should obtain all outstanding VA treatment records. 2. The RO should issue the veteran and her representative a statement of the case on the issues entitlement to service connection for dysmenorrhea and a bilateral leg condition, and initial compensable evaluations for hemorrhoids and allergic dermatitis. Notification should be included advising the veteran of the need to file a substantive appeal within the requisite period of time if she wishes appellate review. 3. If the RO determines that there is evidence of behavior changes at the time of an alleged stressor which might indicate the occurrence of an in-service stressor, or if otherwise deemed necessary, the RO should obtain interpretation of such evidence by a clinician as provided in M21-1, Part III, 5.14(c)(9). 4. The RO should then review the file and make a specific written determination, in accordance with the provisions of 38 C.F.R. § 3.304(f) and M21-1, Part III, 5.14(c), with respect to whether the veteran was exposed to a stressor, or stressors, in service, and, if so, the nature of the specific stressor or stressors established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. 5. Thereafter, if and only if any claimed in-service stressor is corroborated by the evidence or if otherwise deemed warranted, the veteran should be afforded a VA psychiatric examination. The claims file, a separate copy of this remand, and a list of the stressor(s) found by the RO to be corroborated by the evidence must be provided to the examiner for review, the receipt of which should be acknowledged in the examination report. All findings should be reported in detail. Any further indicated special studies should be conducted. The examiners should review the results of any testing prior to completion of the reports. The examiners must express an opinion as to the etiology of any mental disorder(s) no matter how diagnosed found on examination and whether or not the mental disorder(s) found is (are) related to service, or if preexisting service was (were) aggravated in service. Any opinions expressed must be accompanied by a complete rationale. The examiner must determine whether the veteran has PTSD and, if so, whether the in-service stressor(s) found to be established by the RO account for the diagnosis. The examiner should be instructed that only the verified events listed by the RO may be considered as stressors. The examiner should utilize the DSM-IV in arriving at diagnoses and identify all existing psychiatric diagnoses. If PTSD is diagnosed, the examiner must explain whether and how each of the diagnostic criteria is or is not satisfied. Also, if PTSD is diagnosed, the examiner must identify the stressor(s) supporting the diagnosis. If PTSD is not diagnosed, yet the examiner finds the appellant has other psychiatric disorders, the examiner must express an opinion as to whether any such disorder(s) is or are related to the appellant's period of service on any basis, to include on the basis of aggravation. A complete rationale must be given for all opinions expressed and the foundation for all conclusions should be clearly set forth. 6. Thereafter, the RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination report and required opinions to ensure that they are responsive to and in complete compliance with the directives of this remand and if they are not, the RO should implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 7. After undertaking any development deemed essential in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for PTSD with consideration of all pertinent law, regulations, Court decision and M21-1, Part III, 5.14(c). If the benefit sought on appeal is not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case which includes any additional pertinent law and regulations. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until she is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals - 47 - - 1 -