Citation Nr: 0213277 Decision Date: 10/01/02 Archive Date: 10/10/02 DOCKET NO. 00-14 224A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to service connection for a chronic psychiatric disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran had active service from May 1976 to June 1977. Service connection is in effect for status post infection, ingrown toenail of the right and left great toes. This appeal to the Board of Veterans Appeals (the Board) is from rating action taken by the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, SD. FINDING OF FACT The veteran's current psychiatric disability, variously described, cannot be dissociated in significant part from service and/or head trauma therein. CONCLUSION OF LAW A chronic psychiatric disability was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1131,1137, 1153, 5107 (West 1991 & Supp. 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309, 3.310, 4.9 (2001); VA O.G.C. Prec. Op. No. 82-90, Fed. Reg. 45711 (1990). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Assist During the pendency of this appeal, on November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). The Act is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). The new law eliminates the concept of a well-grounded claim, and redefines the obligations of the VA with respect to the duty to assist claimants in the development of their claims. First, the VA has a duty to notify the appellant and his representative, if represented, of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102 and 5103 (West Supp. 2002). Second, the VA has a duty to assist the appellant in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A (West Supp. 2002). The VA has promulgated revised regulations to implement these changes in the law. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a)). The intended effect of the new regulations is to establish clear guidelines consistent with the intent of Congress regarding the timing and the scope of assistance VA will provide to a claimant who files a substantially complete application for VA benefits, or who attempts to reopen a previously denied claim. The Board finds that the VA's duties under the law and recently revised implementing regulations have been fulfilled. The veteran was provided adequate notice as to the evidence needed to substantiate his claim. The Board concludes the discussions in the rating decisions, the statement of the case (SOC), the supplemental statements of the case (SSOCs), and letters sent to the veteran informed him of the information and evidence needed to substantiate the claims and complied with the VA's notification requirements. The RO also supplied the veteran with the applicable regulations in the SOC and SSOCs. The basic elements for establishing service connection have remained unchanged despite the change in the law with respect to duty to assist and notification requirements. The VA has no outstanding duty to inform the appellant that any additional information or evidence is needed. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue on appeal has been obtained. All relevant evidence identified by the veteran was obtained and considered. The claims file contains the veteran's service medical records. The post-service treatment records have also been obtained. The evidence also includes a copy of pertinent Social Security Administration information. Extensive private mental health evaluations have been undertaken and the records for these studies are in the file. Additionally, the veteran has been afforded disability evaluation examinations by the VA to assess the nature of his disabilities. With regard to the adequacy of both the private and VA examinations, the Board notes that the examination reports reflect that the examiners recorded the past medical history, noted the veteran's current complaints, conducted examinations, and offered appropriate assessments and diagnoses. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the veteran's claim. The Board finds that the examination reports coupled with the other evidence of record provide sufficient information to adequately evaluate the veteran's claim. Therefore, no further assistance to the veteran with the development of evidence is required. In the circumstances of this case, a remand to have the RO take additional action under the new Act and implementing regulations would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the veteran are to be avoided). The VA has satisfied its obligation to notify and assist the veteran in this case. Further development and further expending of the VA's resources is not warranted. Taking these factors into consideration, there is no prejudice to the veteran in proceeding to consider the claims on the merits. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Factual Background The veteran's service medical and administrative records are in the file. The veteran's entrance examination in May 1976 reflected neither complaints nor clinical signs of any history or findings of psychiatric problems. Service records show no indication that the veteran had mental health problems during the initial six months of service. In October 1976, the veteran was seen with complaints of experiencing emotional distress and a feeling that he could not adjust to the miliary life. He was evaluated and it was felt that he had an adjustment reaction and situational stress. An appointment was set for a psychiatric evaluation but a report therefrom is not of record. Medications were recommended including Mellaril and Artane. In February 1977, the veteran was admitted to care after having been assaulted in the barracks. He complained of headaches, dizziness and left lower leg pain. Alcohol was not involved (on the veteran's part). He gave a history of having been struck on the left side of his head and his head was repeatedly slammed against the cement floor. It was uncertain whether he was unconscious, and if so, for what period of time. On admission, he was found to have blurred vision and evidence of contusions over the skin of his left leg. Impression was that he had a closed head injury without neurological deficit except for concussion. A complete transcript and associated documents relating to a separation board is of record dated in September 1977. The report noted that civilian court evidence showed that towards the end of March 1977, the veteran had entered a building "without the effective consent of the owner" and endeavored to remove or retrieve some belongings. The details of the civilian court procedure are not of record, but documents show that the veteran pled guilty to the charge for which he was fined $250, and sentenced to 5 years in the penitentiary of which all time was suspended. While confined for the civilian charge, his pay was apparently suspended by the military and by the time he returned to military jurisdiction, he was having even more significant financial problems. The separation board report reflects that virtually all of those military superiors interviewed described him as a good soldier, trustworthy and respectful, and recommended that he receive "good paper", i.e., an honorable or under honorable conditions discharge. The separation tribunal specifically cited that the veteran had a long list of difficulties including the lack of pay, increasing financial worries, and a new additional difficulty, namely that all of his personal belongs had been lost or "misplaced' by the military, and apparently sent to Germany (while he remained in Texas). In explaining the "burglary incident", the veteran said that he knew that what he had done was not probably the right thing to do, but he had tried a variety of other avenues to rectify a bad situation, and he was virtually at his wits end. He detailed the deteriorating circumstances of his life, and explaining the incident as involving some articles or belongings that he was retrieving for a friend, and a separate set of encyclopedias that were purportedly his own, on which he was still paying, and which he wanted back, but about which the resident owner repeatedly lied. The veteran reported that the alleged friend for whom he was trying to retrieve the belongings had told him to just take it all back, i.e., his personal effects as well as the veteran's own books, albeit all of these were located in another's residence. When the veteran tried to do this, he was charged with burglary and never did get the encyclopedia's back so he was "out" just not only the books, and any proceeds he might have received from their sale, but lost the money already paid and still owed for them. The veteran related that the entire episode, including his arrest, had deeply impacted his devoutly religious family, which was already having problems with the family farm and his father's deteriorating health, made worse by his absence. The veteran testified that he had first tried to get help from the military by applying for a hardship discharge, but could not because he had another brother already at home, and it was irrelevant that this brother was unable to help with the family situation. As he worried about this situation, the veteran said that his already sleep-deprived situation got worse, and as he began to sleep less and less, he became even less of an asset to the service. In addition, with his military pay having been suspended, something which took place instantaneously on the sounding of the alert of his being in civilian confinement, it nonetheless took several months to get it straightened out after he was quickly released by the civilian court, during which interim period he was unable to pay the modest monthly amount due on his fine for the civilian charge. This was precipitating additional stress and problems including the possibility of being re-charged or being found in contempt and having the fine amount escalated. He reported that one night, as he was trying to sleep, a fellow came into the barracks and beat him up, that he fell unconscious and was removed by ambulance. His head had been smashed on the floor on repeated occasions, and he reported that he had had headaches ever since. The other individuals testifying at the separation tribunal confirmed that this was in fact the situation, with regard money and pay problems, sleep and the beating. The veteran said that he had tried to get discharged other than on a hardship basis (see above), but he had been told that the only way he could do was to do something "really bad" warranting his ejection from service as a result of court- martial. He had been disinclined to do something "that bad", since other than the so-called burglary incident, he had only a single speeding ticket, and that otherwise, in recent months in the Army, things had simply deteriorated beyond his ability to cope. Throughout the tribunal sessions, none of the others testifying on either side contradicted the testimony given in that regard by the veteran, or indicated that he was anything other than a good soldier who was having an inordinate array of problems in his life. To a certain extent, the board essentially found on his behalf, and the veteran was given a General Discharge under Honorable Conditions. VA outpatient treatment and hospital reports from soon after service separation show recurrent problems with his [service- connected] ingrown toenails. In December 1979, while being primarily seen for the toenail complaints, it was noted that he had headaches, and it was felt that the cephalalgia was of a tension type. He was advised to continue taking Anacin. The veteran was seen again by the outpatient facility later in December 1979. He reported that in addition to his other tribulations, he had some "psychiatric problems" which he characterized as relating to disputes with his father and his career goals. His dad wanted him to go to college or vocational school, and he had finally agreed to do the latter in March 1980. As a result, the veteran said his dad's attitude had improved. He denied having "emotional problems". Another notation in December 1979 was that the veteran had periodic dull to moderate frontal headaches radiating to the occiput. Prolonged reading caused increased headaches but he had not noticed nausea or vomiting. The headache syndrome had increased over the past 2 months and he had been taking Anacin. It was noted that he had also been found to have dizzy spells and also a history of two transient episodes when he had dizziness during the prior summer, on hot days when he had arisen suddenly from a recumbent position while working on clogged dirt in the wheel part of some farm machinery. Extensive private and VA evaluations are of record commencing in the early 1990's relating to treatment for mental health problems. The veteran reported that he was first given medications to include Mellaril and Artane for psychiatric problems in service and that they had worked somewhat at that time. He said that he had had difficulties ever since, as well as headaches and some dizziness. Diagnoses initially related primarily to a bipolar disorder, anxiety and then panic attacks. He was noted to have underlying paranoid personality features as well, and various medications including Lithium, Mellaril, Artane, etc., were tried. These eventually led to apparent tardive dyskinesia or malignant neuroleptic syndrome symptoms in mid-1994. The veteran's social phobia caused him to become more and more unable to go into crowds or interact with those outside his house (i.e., from early 1994, he did not have clean clothing because he could not force himself to go to the laundry). Consistent notations are of record in the clinical files reflecting that the veteran recalled his mental health problems had started in the military, some six months or so after entrance; that he had been given psychiatric medications with some improvement at that time; but that about two months after he had started the medications in service, he had been beaten up, experienced a serious concussion and as a result, had greater problems. Additional private evaluations from 1992 have recently been submitted showing diagnoses of generalized anxiety disorder, paranoid personality disorder, with Global Assessment of Functioning (GAF) level of 40. An extensive evaluation was undertaken in May 1994, after the veteran's family had encouraged him to seek care. He said that ever since the head injury in service, and discharge in 1977, he had been "euphoric", like he had an Adrenalin rush. Since that time, he had lived in many cities and had eventually sought help from a veterans service organization in MN. In addition to the feelings of euphoria, he was fatigued and felt like he was bouncing off the four walls. Lorazepam had initially been given. The veteran was noted as having many anxious moments with profuse sweating absent provocation, many interpersonal fears, and mild insomnia. He was seen on a weekly basis. He had been on various medications including Amitriptyline which had been stopped about 3 months before as it helped his sleeping and back pain but did not help with his anxiety. The examiners noted that the differential diagnoses options were wide-ranging and could include attention deficit disorder, depression, panic disorder, malingering, chemical dependency, organic brain syndrome, and personality disorders including avoidant, anti-social, histrionic, schizoid, schizotopal and paranoid. It was noted that there was a possibility of organic components as a result of the inservice closed head injury, but a magnetic resonance imaging (MRI) procedure was deferred since this had been stable for some time. In July 1994, an inquiry was made by VA of his private treating physicians as to any possible relationship between the veterans' inservice closed head injury and his current psychiatric problems. One of the examiners who is shown on the ongoing records as having seen him on numerous occasions noted that (r)egarding his medical disability, patient complained of stress reaction in the military 10-27-76 and was started on Mellaril and Artane and was felt to be on that until discharge 11-77 he states. His head injury occurred four months after he was started on the Mellaril 2-2- 77. The head injury, therefore, did not precipitate his difficulties, but there would be a question of whether it exacerbated it. The medical records obtained showed a close head injury with no demonstrable neuro-deficit. [emphasis added]. Because of the ongoing question as to organicity, and the specific inquiry that had been made by VA as to causation, it was recommended that further specialized neurological testing be undertaken and arrangements were to be made to do so. Another VA examination was undertaken in October 1994. The veteran gave a detailed history of the inservice beating, at which time he reported that a drunk sergeant had come into the barracks, grabbed him by the hair and pounded his head repeatedly on the cement with resultant visual disturbance and possible loss of consciousness for which he was taken to the dispensary. [The examiner reported that he was unable to find the service record notations to back up the story.] The veteran said that starting soon after service separation, he had moved around a great deal and had some 50 jobs, none for longer than 4 months. The various psychiatric alternative diagnoses were noted. The examiner noted in part that (A)t best, the diagnosis is extremely unclear in this veteran. It is highly recommended that the testing results from the Mayo Clinic be obtained and that neuropsychological testing be undertaken if these result do not provide it. Private treatment records from 1997 are now in the file showing ongoing similar problems and diagnoses, with noted history of head trauma. A report is of record from MM, M.D., a private psychiatrist associated with a community counseling service. He had evaluated the veteran in November 1998, and his detailed report is of record. The veteran had given a detailed history of the incident in service which involved his sergeant bashing his head on the cement floor. The summary diagnostic impression was that under Axis I, the veteran had personality change due to head trauma, labile type, and generalized anxiety disorder and social phobia; under Axis II, none; and Axis III, multiple sclerosis (MS). Axis IV reflected occupational and economic problems. His GAF level was felt to be 41 at the time and a maximum of 50 in the prior year. The examiner noted that the "perseverative" quality of his speech and anxiety do suggest some sort of organic deficit which he relates chronologically to the head injury sustained while in the military service. Patient has learned from a neurologist that his multiple sclerosis is likely not associated with that injury and that follows for the known patho-physiology of multiple sclerosis is an auto immune problem. The MS does obfuscate the issue of personality change, which I believe is due to his injury in that MS lesions can cause personality change as well. However, the MS is a fairly recent diagnosis and does not account for the difficulties, which are implicit in his shiftless lifestyle following service.[emphasis added] An addendum was subsequently provided from the psychiatrist who opined that the veteran's primary psychiatric disorder was an anxiety disorder. It was also noted that his history was consistent with a generalized anxiety disorder as well as social phobia. "It is also very suggestive of a brain injury implicit in the diagnosis I made of personality due to head trauma, labile type." Extensive evaluative reports are of record from the Mayo Brain Injury Outpatient Program and associated Mayo facilities. The examiners noted that the veteran had been referred by his psychiatrist with depression and extreme anxiety, and what was diagnosed as bipolar disorder/anxiety disorder, and for which he was receiving Lithium and Klonopin. It was noted also that there was a need to delineate the extent of cognitive difficulties in the likelihood that the veteran's inservice history of brain injury was contributing to his current problems. Specifically, it was noted that in the 1970's, he sustained a head injury while in the military service when his head was struck against a concrete floor during an assault. He remembers most of the incident and the time shortly afterwards and indicates a loss of consciousness of less than 10 minutes. He apparently was started in Mellaril while in the military for treatment of a "stress reaction" four months prior to his traumatic brain injury. Neuropsychological profiling was noted in detail including evidence of mild abnormality, primarily evidence in efficiency of learning/memory and higher level abstract reasons/problem solving. Mild fluctuation was shown in consistency of attention/concentration. His psychiatric components were also described in detail. The mild neurological compromise shown was felt to not be suggestive of a typical profile associated with residuals of traumatic brain injury and his enrollment in the Brain Injury Outpatient Program was not recommended. The veteran again underwent comprehensive and extensive psychological assessments by a private specialist, in July 1999, report from which is of record. In noting the reasons for the assessment, the examiner noted that the veteran had reportedly suffered head trauma as a result of his having his head on the concert after his Sgt. knocked him down while in the military. There were questions about organic and emotional problems. Numerous tests were undertaken and are reported in detail by the examiner to include interviews, review of clinical records, Wechsler Adult Intelligence Scale, 3rd Edition (WAIS-III), Ingel's Memory Task, Controlled Word Association Test, Cognitive Difficulties Scale, Minnesota Multiphasic Personality Inventory - Revised (MMPI-2), Millon Clinical Multiaxial Inventory - 3rd Edition (MCMI-III), and Post Traumatic Stress Diagnostic Scale (PDS). The psychiatric diagnoses were characterized, in summary, under Axis I as delusional disorder, and generalized anxiety disorder; and under Axis II were schizoid personality disorder and avoidant personality disorder. In a separate detailed addendum, a specific determination was also rendered with regard to the overall assessment and the organicity involved. The examiner noted that the aforementioned evaluations had shown that the veteran's psychiatric symptomatology defies neat psychiatric classification. His condition is atypical and doesn't fit neatly into current (DSM-IV) diagnostic classification. A review of his past psychiatric records suggests that (the veteran)'s mental status examinations have varied over time and there is some question as to the extent to which (he) assesses psychological insight and willingness to describe symptomatology. Some of the difficulties that (the veteran) experiences involve overall personality organization. He has failed to develop adequate internal cohesion and coping strategies. His psychological disorder is the result of a number of factors. (The veteran) has habitual and maladaptive methods of relating, behaving, feeling and thinking. As noted in my report, he demonstrates reexperiencing symptoms, avoidant symptoms and arousal symptoms consistent with Post Traumatic Stress. In the PDS, (he) identified various traumatic events that may have influenced his experiencing excessive anxiety symptoms. In all likelihood, his experience of having been assaulted in the military contributed significantly to his psychological difficulties, but the "state of the art" of psychological assessment is such that it is difficult to estimate the extent to which (his) anxiety type symptoms are specifically a result of having his head banged into the cement by his sergeant. [Emphasis added]. Another VA psychiatric evaluation was undertaken in December 1999, report from which is of record. The psychiatric diagnosis under Axis I was bipolar affective disorder, probably mixed type, in partial remission; and anxiety disorder, NOS, with traits of generalized anxiety disorder, social phobia and obsessive compulsive disorder; and history of pathological gambling. Axis II was personality disorder. Axis III was shown as MS, chronic bronchitis and history of head trauma in 1977. Axis IV was social isolation with an estimated GAF at 50. The examiner opined that the veteran had been experiencing episodes of sharp mood swings ranging from euphoria to depression. It is known that serious head trauma may lead to social disinhibited, inappropriate and assaultive behavior, I am not sure that the patient has any typical residuals following the head trauma in 1977. In my opinion (the veteran) has been suffering from bipolar affective disorder. It is not really clear to me whether there is any direct linkage between his bipolar effective disorder symptoms and traumatic brain injury. It is this examiner's opinion that it is less than likely the patient's current symptoms are due to assault in his barracks on February 2, 1977. [emphasis added] III. Criteria Service connection may be granted for disability due to disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 2002). If a chronic disorder such as a psychosis is manifest to a compensable degree within one year after separation from service, the disorder may be presumed to have been incurred in service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 2002); 38 C.F.R. §§ 3.307, 3.309 (2001). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2001). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2001). Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the VA to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. See 38 C.F.R. § 3.303(a). Similarly, to establish service connection for an injury, a veteran must be injured while he was in service. See Cahall v. Brown, 7 Vet. App. 232 (1994). Service connection may also be granted for disability shown to be proximately due to or the result of a service-connected disorder. See 38 C.F.R. § 3.310(a) (2001). This regulation has been interpreted by the Court to allow service connection for a disorder which is caused by a service-connected disorder, or for the degree of additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder. See Allen v. Brown, 7 Vet. App. 439 (1995). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1132, 1137; 38 C.F.R. § 3.304 (2001). Under the provisions of 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306 (2001), a preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a finding that the increase in disability is due to the natural progress of the disease. The regulation further provides that aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). Clear and unmistakable evidence is required to rebut the presumption of aggravation when the pre-service disability underwent an increase in severity during service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). However, temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993), citing Hunt v. Derwinski, 1 Vet. App. 292 (1991). A pre-existing injury or disease will be considered to be aggravated by service when there is an increase in disability during service, unless there is a specific finding that the increase was due to the natural progress of the disease. 38 C.F.R. § 3.306(a) (2001). If a disability is found to have preexisted service, then service connection may be predicated only upon a finding of aggravation during service. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306(b) (2001); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Notwithstanding the foregoing, congenital or developmental defects such as personality disorders are not diseases or injuries for the purposes of service connection. 38 C.F.R. § 3.303(c), 4.9 (2001); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). However, see VAOPGCPREC 82-90 (July 18, 1990) (in which the VA Office of General Counsel held that service connection may be granted for a congenital disorder on the basis of in-service aggravation). See VAOPGCPREC 82- 90, 55 Fed. Reg. 45,711 (1990) [a reissue of General Counsel opinion 01-85 (March 5, 1985)] which in essence held that a disease considered by medical authorities to be of congenital, familial (or hereditary) origin by its very nature preexist claimants' military service. The opinion went on to hold, however, that service connection for congenital, developmental or familial diseases could be granted if manifestations of the disease in service constituted aggravation of the condition. See also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514- 15 (1993). A veteran who served during a period of war, or a veteran who had peacetime service after December 31, 1946, is presumed to have been in sound condition except for defects, infirmities or disorders noted when examined and accepted for service. The presumption of sound condition attaches only where there has been an induction examination in which the later complained-of disability was not detected. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Verdon v. Brown, 8 Vet. App. 529 (1996). Clear and unmistakable evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. §§ 1111, 1137; 38 C.F.R. § 3.304(b). With respect to medical opinions, in general, an opinion based on an inaccurate history has essentially no probative value. See Kightly v. Brown, 6 Vet. App. 200 (1994). See also Grover v. West, 12 Vet. App. 109 (1999) (holding that due to the lack of service medical evidence indicating a fracture suffered during service, any post-service medical reference to a fractured foot suffered by the veteran in 1975, without review of his service medical records, could not be considered competent evidence). The Board is not bound to accept medical opinions which are based on a history supplied by the veteran, where that history is unsupported or based on inaccurate factual premises. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guimond v. Brown, 6 Vet. App. 69 (1993). A speculative relationship is not enough to support a claim. See Obert v. Brown, 5 Vet. App. 30 (1993). See also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that a physician's statement that a service-connected disorder "may or may not" have prevented medical personnel from averting the veteran's death was not sufficient); Beausoleil v. Brown, 8 Vet. App. 459 (1996) (holding that a general and inconclusive statement about the possibility of a link was not sufficient); and Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (holding that there was a plausible basis for the Board's decision that a disability was not incurred in service where even the medical evidence favorable to the appellant's claim did little more than suggest the possibility that the veteran's illness might have been caused by his wartime radiation exposure). Although the foregoing cases involved assessing the matter of whether medical opinions rendered claims "well-grounded" (a legal principle which was eliminated by the VCAA) the principles discussed in such cases are nevertheless applicable when weighing evidence and deciding a claim on the merits. The Board has the responsibility to assess the credibility and weight to be given to the competent medical evidence of record. See Hayes v. Brown, 5 Vet. App. 60, 69 (1993); Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The veteran may provide lay evidence, including his own lay statements and those of other acquaintances. However, these lay individuals do not possess the requisite medical expertise, credentials, or training to render a medical diagnosis or a competent opinion as to causation. See Routen v. Brown, 10 Vet. App. 183, 186 (1998), aff'd, Routen v. West, 142 F.3d 1434 (Fed. Cir. 1988); YT v. Brown, 9 Vet. App. 195, 201 (1996); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). The Board has an obligation to seek additional medical evidence. See 38 U.S.C.A. § 7109(a) (West 1991); 38 C.F.R. § 20.901(a) (2001); see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) ("If the medical evidence of record is insufficient, or, in the opinion of the [Board], of doubtful weight or credibility, the [Board] is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or [quoting] recognized treatises"). The Court has recognized that the Board is not compelled to accept medical opinions; rather, if the Board reaches a contrary conclusion, it must state its reasons and bases and be able to point to a medical opinion other than the Board's own, unsubstantiated opinion. Colvin, 1 Vet. App. at 175. It is incumbent upon the Board to weigh doctors' opinions so as to determine their relative weight, and the Board may favor the opinion of one competent medical expert over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). IV. Analysis From the outset, the Board would stipulate that there is nothing simple about the veteran's overall psychiatric picture; it has been described as a "constellation" of many elements. Commonly, psychologists and psychiatrists who have evaluated the veteran have described his symptoms as "atypical" with regard to one or more of the differential diagnoses he carries. And as one psychiatric specialist pointed out, the intricacies of an overall accurate clinical diagnosis are made somewhat more tortuous by the very nature of the cognitive impairment which restricts his ability to articulate his own indicators. There is some irony in that pursuant to Espiritu, his mental impairment precludes authentic self-observations, the one thing the veteran could use to help his own cause. In any event, the veteran must not be penalized in the adjudication of his claim by virtue of the complexity of his symptoms and/or diagnoses. Fortunately, in this case, a multiplicity of diagnostic options does not necessarily negate a timely and fully satisfactory addressing of the issue with regard to the causative factors relating to any one or the aggregate of these factors. To advance that effort, the Board observes that VA and private psychiatric and psychological assessments now of record, including from several nationally recognized private experts, are particularly detailed and meticulous, and provide an entirely adequate basis for resolving the case forthwith and to the veteran's satisfaction. Simply stated, there is no evidence that the veteran manifested any psychiatric disorder, even in the form of particular personality "quirks", prior to service or for the first 6 months of service. After a half a year or so of service, the veteran acknowledged that he was having some stress due to a variety of circumstances. It was felt that he had developed a situational response and emotional distress described as an adjustment reaction and for which he was given Mellaril and Artane. On retrospect, that has been described as anxiety as well. This appears to have been the initial mental health change in, and reasonably attributable to, service. Then and now, the veteran has conceded that the medication did him some good, although his specific circumstances did not apparently get much better. His superiors would later relate that he was a good soldier and endeavored to do his best, but due to an error in judgment, he got into trouble with the civilian authorities. As detailed above, this precipitated a worse inservice fiasco and secondary civilian concerns, all of which were concurrent with other military-oriented problems not of his own making. While the veteran was already experiencing some anxiety and depression, and having trouble sleeping anyway, someone beat him up and repeatedly smashed his head on the barracks's cement floor. After that incident, the veteran developed concussion symptoms, dizziness and headaches, some of which would continue for decades. That incident appears to be have contributed another modification or alteration to his mental health in, or attributable to, service. And while the incident may have concurrently provided the basis for even more increased anxiety, several experts have opined that in tandem, this also may well have caused a classic, fairly fundamental transformation, (as contemplated under aforecited regulations, judicial interpretations and General Counsel opinion), in essence a superimposed disability aggravating any underlying personality dysfunction, turning it into something more nearly approximating a lasting cognitive aberrance. The Board finds this to be entirely logical as well as consistent with the evidentiary circumstances in this case. Immediately after separation, the personality of the young man who before service had been a farmer's son and helped at home, seemed to have taken a decided turn as he began to live an undirected rather haphazard lifestyle, with many residencies and dozens of jobs, none for more than a few months. According to the veteran, his father and family were unhappy with his occupational or educational "dithering" from the start, and his indecisiveness in whether to go to college or vocational school became an immediate issue. The veteran was soon seen by VA for anxiety and difficulty coping, as well as ongoing headaches. On repeated occasions, it was noted that he recalled that his then-continuing symptoms seemed to have started concurrent with the trauma to his head in service. In this context, it appears that this is the sort of observation that is encompassed within Espiritu, as it is not diagnostic but merely a statement of recollection within his capacity to recall. The symptoms have since clearly been identified as having organic components, and most examiners have concurred that these are attributable to the inservice head-bashing incident. In accordance with regulatory and judicial guidelines, the Board has assessed the relative merits of various medical expert opinions. Even the least favorable among them is equivocal at best, and endorses the opinions of the other experts that there is an atypical component to the veteran's apparent cognitive problems which may be due to head trauma. That said, and given that the nature of tests administered by that expert compared to those more extensive tests given by others, that examiner's secondary opinion, which tends to discount confirmation of an essential impact by the head trauma, becomes of lesser credibility. The other expert opinions, including some based on exhaustive and many-phased testing procedures, are virtually unanimous in the conclusion that in one or more ways, the veteran's inservice head trauma did have measurable and chronic influence on his mental health or the lack thereof, a condition which has deteriorated considerably since then. Based on these reasoned, learned options, the Board finds that there are perhaps three alternative means suggested by the evidence in which the veteran's psychiatric disabilities are related to service. First, there may have been the development of an anxiety after the first 6 months of service, a neurotic response to the stresses thereof; secondly, there may well have been some underlying personality pathologies which had not previously played-out, but which were the aggravated by head trauma, and accordingly, measurably exacerbated; and thirdly, that there is an additional psychological pathology with neurological components which may be directly due to the inservice head trauma. Thus, however the current diagnosis may be phrased, there is an ample foundation for finding that the disability is reasonably due to or was significantly impacted by service or incidents therein. The sort of factual scenario indicated in this case is addressed by the provisions of 38 U.S.C.A. § 5107(b). Under this section, the VA is statutorily required to resolve the benefit of the doubt in favor of the veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). After resolving all such doubt in the veteran's favor, the Board concludes that the medical evidence of record supports the finding that his psychiatric disabilities, with admittedly multiple components, are reasonably a product of service and therefore, service connection is warranted. ORDER Service connection for the veteran's current chronic psychiatric disability is granted. JEFF MARTIN Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.