Citation Nr: 0524419 Decision Date: 09/07/05 Archive Date: 09/13/05 DOCKET NO. 02-07 176 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The veteran had active military service in the United States Army from August 1974 to May 1980, and served in the U.S. Navy from January to October 1982. This matter comes to the Board of Veterans Appeals (Board) on appeal from a March 2001 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In November 2003, the Board remanded the veteran's case to the RO to comply with her request for a hearing before a Veterans Law Judge (VLJ). In June 2005 the veteran, sitting at the RO, testified via video-conference, with the undersigned VLJ sitting at the Board in Washington, DC. The Board observes that, in a November 2003 written statement, the veteran's accredited service representative appeared to raise a claim for service connection for an acquired psychiatric disorder. That matter was then referred to the RO in the Board's November 2003 remand. In the interest of due process and fairness, the Board believes the issue as currently stated on the first page herein, which incorporates both of the claimed disorders, most accurately represents the current status of the veteran's claim. FINDINGS OF FACT 1. The objective and competent medical evidence of record preponderates against a finding that any currently diagnosed major depression with psychotic features is related to the veteran's periods of active military service. 2. The veteran has a current medical diagnosis of PTSD, and at least one VA medical examiner has related the diagnosis to her claimed in-service sexual assault/rape. 3. The veteran's claimed in-service stressor is not related to combat. 4. The occurrence of the veteran's claimed in-service sexual assault/rape is not supported by credible corroborating evidence. 5. The current diagnosis of PTSD is based upon unsubstantiated reports of a stressor, or stressors, as provided by the veteran. CONCLUSION OF LAW An acquired psychiatric disorder, including PTSD, was not incurred during the veteran's periods of active military service. 38 U.S.C.A. §§ 1131, 1110, 5103-5103A, 5107 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background Service medical records indicate that, on a report of medical history completed in October 1975, the veteran checked "Yes" as to having depression or excessive worry and periods of nervous trouble, and noted that she had emotional problems that were being treated at a mental hygiene clinic at Fort Eustis. An undated service examination report reflects that when the veteran was examined for replacement purposes, a psychiatric abnormality was not found. In February 1980, the veteran was referred to the psychiatric clinic for possible phobia due to her gas mask training. It was noted that she was treated for anxiety due to putting on her gas mask. Upon examination, the veteran reported a traumatic and chaotic childhood that included being confined to her closets. It was also noted that she had a number of other conflicts, and previously received psychiatric treatment. The clinical impression was mixed anxiety neurosis with phobic and hysterical components, and it was noted that the veteran had underlying problems which would benefit from psychotherapy. On a report of medical history completed in April 1980, when she was examined for separation from the Army, the veteran checked "Yes" as to having experienced depression or excessive worry and difficulty sleeping, and said she did not know whether she had nervous trouble. When she was examined at that time, there was no indication of psychiatric abnormality. On a report of medical history completed in October 1981, when she was examined for enlistment into the Navy, the veteran again checked "Yes" as to having nervous trouble and frequent trouble sleeping. A psychiatric disorder was not noted on examination, and she was found qualified for active service. Clinical records show that in March 1982 the appellant was hospitalized for complaints of chest pain and dyspnea. The discharge diagnoses were atypical chest pain, not of ischemic cardiac origin, and anxiety. In April 1982, the veteran was seen for situational stress temporomandibular joint (TMJ) pain, and Valium was prescribed. In June 1982, the veteran was referred for a psychiatric evaluation. It was noted that she had a pressure-type job with much stress within deck departments, and took orders from younger, more senior people. She described several episodes of crying emotional upset within the past few months, most recently associated with feelings of suicide. It was also noted that the veteran had liked military service very well until her current assignment as a boatswain's mate, where she felt physically inadequate for the work and thought that she was disliked, resented, and systematically treated unfairly by peers and supervisors in her division. She had reacted to this with a feeling of depression, poor appetite, unknown weight loss, and thoughts of injuring others or herself. She thought she would resume prior military adjustment if she were able to escape the present situation. The examiner's diagnosis was normal reaction to situation maladjustment; no psychiatric disease. A change of rate was recommended, if possible. In September 1982, clinical records reflect that the veteran was referred for an oral surgery examination. It was noted that she had been in a high-stress situation for the last three months, was treated with Valium for anxiety, and saw a psychiatrist approximately two months earlier. When she was examined for separation from service in September 1982, a psychiatric abnormality was not noted. Post-service, VA and non VA medical records and examination reports, dated from 1997 to 2002, and the veteran's oral and written statements in support of her claim, are associated with her two-volume claims file. In an April 1997 private confidential psychiatric report, M.L.K., M.D., reported that the veteran was in her 13th marriage. She gave a history of physical abuse as a child and in her prior marriages, and also described an alcohol problem. She said she had cared for a quadriplegic stepson during 1995 and 1996, and her current husband had undergone back surgery in 1996. She said she felt as if she was caring for two invalids. The diagnoses was acute anxiety reaction and alcohol abuse. Dr. K. opined that it would seem that the veteran had a work-related problem as, prior to her 1995-96 episodes, she was not disabled from work in any way, nor had she ever sought psychiatric treatment or been hospitalized for psychiatric problems. In Dr. K.'s opinion, 50 percent of her difficulties were work-related and had an industrial causation. VA medical records indicate that in September 1997 the veteran reported having a nervous breakdown the previous year due to family circumstances, and had also been receiving workers' compensation benefits, which had expired. She reported worsening anxiety attacks in the past year. The assessment was questionable major depression with anxiety, and a psychiatric consultation was recommended. It was also suggested that she visit the addiction clinic for her alcohol abuse. A February 1999 VA mental health intake record indicates that the veteran was treated for a psychiatric disorder. The veteran reported that she was discriminated against in service because of her gender, experienced "mental abuse", and was "sexually harassed in [the] Army and Navy". The diagnoses at that time included an alcohol-induced mood disorder, alcohol dependence in early partial remission, and a need to rule out impulse control disorder and/or bipolar disorder. In March 1999, the RO received the veteran's written statement regarding the specifics of her alleged stressor events in service. She said that in November 1974 she was informed by a superior that she was the first female assigned to him, and was not wanted there. She reported being verbally abused by her sergeant In May 1978, and said she started drinking heavily at that time. The veteran stated that in April 1982 she got into trouble with the ship's captain for not having flags which she said were hidden from her to get her into trouble. In June 1982, she was sent to the Naval Hospital because she felt as if she were having a nervous breakdown. In September 1982, the veteran said she sought help regarding her problems aboard ship. In October 1982, at separation, she overheard the boatswain say it was time to celebrate, now that she was gone. The veteran stated that she did not recall the names of the people and doctors with whom she had spoken about her problems, and did not recall where the hospital in San Francisco was located. After her 1982 discharge, she said she wrote to the "CNO" (Chief of Naval Operations) of the Navy about the harassment to which was subjected, but did not receive a response and did not have a copy of the letter. According to April 1999 VA medical records, the veteran was then currently married, for seven years, and in her 13th marriage. The diagnosis at that time was mood disorder, not otherwise specified, with some aspects of PTSD. A June 1999 VA medical record reflects PTSD, with a history of sexual assault. In June 1999, the VARO afforded the veteran, at the time 54 years of age, a private psychiatric examination performed by E.R.D., M.D., a psychiatrist and neurologist. According to the examination report, the veteran had last worked in January 1998, as a health care provider, paid by the State of California to care for her stepson who was a quadriplegic since May 1995. She was unable to return to work, as she could not handle stress. The veteran said she could "drink a twelve pack in a heartbeat" and her last alcohol use was approximately six months earlier. The veteran reported she had earned her general equivalency diploma from high school, and completed more than two years of college. She said that in the Army she was not allowed to work in her specialty as a boat operator because she was a woman. She served in the Navy for a few months in 1982, with an occupational specialty of boatswain's mate, and had no combat exposure or foreign service. It was noted that the veteran received outpatient treatment on one occasion while in the Navy, when Valium was prescribed. She returned to active, unrestricted duty. It was further noted that she was separated from service after requesting a hardship transfer to shore duty. Upon examination, the diagnosis was depressive disorder, not otherwise specified. Dr. D. said that "[t]he veteran does not come close to meeting the diagnostic criteria for [PTSD]" and further commented that it did "not appear that her current 'depressive disorder, not otherwise specified' is in any way service connected." Dr. D. said that the veteran's personality disorder would, by definition, antedate her military service. An October 1999 VA medical record indicates that PTSD was diagnosed two years earlier. The veteran denied suicidal ideation, but had threatened her husband with an ice pick two weeks earlier. According to VA mental hygiene records, dated from May 2000 to August 2001, the veteran received regular outpatient psychotherapy. The May 2000 VA mental hygiene clinic intake evaluation record indicates that the veteran was referred for evaluation and treatment of depression and PTSD, for which she was treated at another VA medical facility. The veteran reported she was almost a total recluse and complained of a depressed mood, insomnia, not eating well, with no recent weight change, anxiety and constant worry, occasional panic attacks, periods of intense fear and even violence, intrusive memories of military trauma (harassment, physical abuse, and a rape); sleep-related difficulty, nightmares, and flashbacks related to the trauma and blocking about aspects of the trauma, e.g., peoples' names. She also said she had episodes of dissociation. The veteran said her PTSD, depression, and anxiety symptoms began after experiencing trauma in service including constant harassment by men and physical abuse, e.g., being beaten on the head and body with the butt of a gun during a training exercise, and being raped once. Her symptoms were exacerbated after she experienced a "nervous breakdown" in September 1996 due to caring for her back- injured husband and quadriplegic stepson. The veteran gave a history of prior trauma including sexual abuse by her stepfather, beginning at age six and lasting for several years, and her mother taking her two oldest children from her when she was 22. She occasionally drank as much as two to three cocktails, with the same number of beers, to a quart of hard liquor in a day, and characterized herself as an alcoholic. Upon examination, the Axis I diagnoses were PTSD, with significant depression and anxiety and alcohol dependence. In June 2000, veteran underwent VA examination for PTSD. According to the examination report, the examiner reviewed the veteran's medical records. The veteran, who was 55 years old, said that in 1976 she participated in an escape and evasion exercise in Fort Story, Virginia, when she was captured by "enemy forces", hit in the head and body with rifles and, thereafter, experienced difficulty with anxiety and irritability symptoms. She felt singled out because of her gender. The veteran was unable to provide the names of any of the alleged perpetrators of her physical abuse. She said did not talk with fellow soldiers or seek any care from a chaplain, physician, or other service personnel about those incidents. During her entire first enlistment, she was subject to verbal abuse. Her sergeant called her a "dumb bitch" and verbally abused her in other ways. She transferred to another company where the situation was somewhat improved. The veteran also said that in the Navy she was raped by a fellow sailor; she was unable to provide the name of the individual or provide details regarding the exact circumstances because she was markedly intoxicated, according to her own admission. The veteran said that at that point she did not report the rape to anyone, nor did she seek any sort of treatment with a health care provider, a chaplain, or fellow soldiers. In addition, the VA examination report indicates that the veteran said she was married four times before she enlisted in the Army in 1974, and that she was a victim of sexual or physical abuse during her childhood, specifically abuse by her stepfather. She was the victim of domestic violence in a majority of her 13 marriages, and was alcohol and tobacco dependent. It was noted that previous diagnoses included anxiety, depressive disorder, and alcohol abuse disorder, with a question of bipolar illness and borderline personality disorder. She received outpatient psychotherapy at a VA medical center. It was noted that the veteran did not have any documented mental health treatment in service, although she told the examiner she was evaluated at a military medical facility in San Francisco, California, but there was no record of this hospitalization or any other record regarding treatment for a substance abuse or emotional disorder. Upon clinical evaluation, the VA examiner concluded that it appeared the veteran "may have current diagnoses of [PTSD], but it is unclear if these symptoms are related to the specific stressors that she alleges occurred in the military or if these symptoms are related to her earlier life when she was physically and sexually abused by a stepfather and multiple spouses." The VA examiner further stated that the veteran was currently suffering "from anxiety as well as major depressive disorder and also the presence of an alcohol abuse disorder . . . . She indicates she is impaired in the social and vocational areas and I agree, but I question whether this is based solely on service connected incidents." The final diagnoses included generalized anxiety disorder with episodic panic attacks, as well as elements of PTSD, the latter not clearly service-connected; major depressive disorder; and alcohol abuse disorder. In a September 2001 signed statement, a staff psychologist at the VA Medical Center (VAMC) in Prescott, Arizona, said that she had treated the veteran since May 2000 and that the veteran was diagnosed with PTSD, "which appears" to be related to a sexual assault and sexual harassment she experienced in service, as well as a history of alcohol dependence, now in remission. The veteran underwent VA examination in August 2002. According to the examination report, the examiner reviewed her medical records. The veteran complained of nightmares regarding her rape in 1982. She said she lost control of herself and was disinterested in sex. She dated her problems to 1982. She had anger in service, and felt she was verbally abused. The veteran said she did fine for the first few years but, in 1995, threatened to injure or kill her supervisor. She was discharged and placed on workers' compensation for psychiatric reasons. Her husband subsequently injured his back, and she cared for him and her quadriplegic son. She expressed displeasure with the psychiatric report prepared by Dr. K. which had contained the diagnosis of acute anxiety reaction and alcohol abuse. It was noted that her other diagnoses included depression, PTSD, a personality disorder, alcohol dependence, and an impulse control disorder. The VA examination report indicates that the veteran had active military service from 1974 to 1980, and during 1982. She denied serving in a combat zone, but said she believed she spent several months doing mop-up work in Cambodia, sometime from December 1974 to March 1975, and had dreams about this. Her specific complaints derived from her naval service. The veteran said the Navy used her and her husband as examples and simultaneously sent them out to sea. She said she quit the Navy to care for her daughter. She also complained about a rape in service, the circumstances of which she desribed. She was married during that time, but she was not with her husband. She said she was drinking heavily at a party on an air force base, and returned to her motel room. Several hours later she awoke with an officer she knew on top of her. He raped her, and she did not report him, as he was her supervisor. She had experienced nightmares about the rape since 1982, and did not tell anyone about the rape until recently. The veteran's other complaint was that when she left the Navy they gave her a discharge rank that would not allow her to reenlist. This upset her because she wanted to go back into service, but was unable to do so. The veteran gave a history of being a victim of child sexual molestation and physical abuse. She corrected this by saying that this was "normal" for the culture in which she was reared at that time, and she did not remember being disturbed by the sexual molestation. She joined the military at age 29 after she had 5 marriages. She was married 13 times to 11 different men, and had 3 children. She described symptoms that she said were related to the rape event, including sleep difficulty, recurring dreams and nightmares, flashbacks, and outbursts of anger. She had attempted suicide in 1989. She had gained 30 pounds in the last three months. The veteran said her violent nightmares began in October 1996 when she had nightmares about her demanding stepson. Prior to that time, it was noted that the veteran did not seem to report any symptoms of PTSD or to have any mental health issues. The VA examiner reviewed the veteran's stressor statement (received in March 1999) regarding her PTSD, and noted that the veteran did not mention the rape in service. Rather, it was noted that the veteran's statement dealt more with feeling humiliated and unwelcome in service, and some physical problems. Upon clinical evaluation, the VA examiner said that it appeared that the veteran had a current diagnosis of major depression with psychotic features, with alcohol abuse in remission, and a disorder of impulse control. In the VA examiner's opinion, the veteran did not meet the criteria for PTSD. The examiner said it was very unusual that she would have no psychiatric history until 1996, and noted that Dr. K.'s detailed report documented a well-functioning woman who did not report PTSD symptoms prior to 1996. At that time, there appeared to be a convergence of problems related to the veteran's injury and her stepson's physical and medical problems, and her impulse control problems that led to her "nervous breakdown". It was noted that there was a "limited report of any rape" even by the veteran in her testimony to the Board. It was further noted that, in February 1999, the veteran was diagnosed with psychosis related to a drug-induced state, and with alcoholism, and she refused any substance abuse treatment and denied that it was a problem. A borderline personality disorder, provisional, was also diagnosed. In addition, another psychiatrist had diagnosed a mood disorder, with some aspects of PTSD. The VA examiner commented that it appeared the veteran mentally deteriorated after the 1996 incident involving her work, and social factors combined to threaten her mental stability. The VA examiner was unable to "link her present mental status with her service time based on her records, as well as her presentation." As to the rape incident in service in 1982, the veteran had told examiners she was grossly intoxicated at the time and did not report or even think to report the incident to anyone. The VA examiner said this raised "questions regarding reliability of her perceptions and memory of the event". The veteran minimized to the examiner any sexual abuse problems or issues she had when she was young, but a review of the record indicates that these were, in fact, "a significant problem, as was her early childhood, as well as throughout her life." It was noted that the veteran had "extreme physical abuse, as well as emotional abuse by many of the men that she married". She also had this pattern prior to going into service. In a November 2004 written statement, the veteran said that during the 1970s and 1980s it was inappropriate for a female to report incidents of sexual harassment. She described experiencing pressure and difficulties during her first few months of service in the Navy in 1982. In June 1982, she felt as if she was having a nervous breakdown, and requested to see a mental health care professional. She talked with a doctor, who recommended she change jobs. She was subsequently reassigned to another position, where she got along well with others. The veteran said that on the July 4th weekend, in 1982, she got drunk and awoke in a motel with her leading petty officer raping her. He told her no one would believe her claims. In September 1982, she jumped ship and told a female officer on base about the harassment, but not about the rape. That officer told an executive officer, who advised that if the veteran returned to her ship no consequences would be incurred. The veteran said she returned and went to the infirmary, where she was given Valium and confined to sick bay. Subsequently, the executive officer recommended that she be discharged. During her June 2005 Board hearing, the veteran testified that she was raped on or about [redacted] in [redacted], [redacted], by a petty officer 1st class, E6, who was her direct commander until she switched to working in the laundry. The rape was unreported, and she told no one about it until 1991, when she told her current husband about the event. The veteran also experienced sexual harassment while stationed at Fort Story and Fort Eustis. Her first post- service medical treatment was in 1996, when she saw Dr. K. because of a nervous breakdown, for which she filed a workers' compensation claim. She testified that she had no memory of serving in Cambodia, and the military said she did not have any service there, but she had nightmares about it. II. Legal Analysis A. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2004). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2005); 38 C.F.R. § 3.159(b) (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim, in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). In the Mayfield case, the Court addressed the meaning of prejudicial error (38 U.S.C.A. § 7261(b)), what burden each party bears with regard to the Court's taking due account of the rule of prejudicial error, and the application of prejudicial error in the context of the VCAA duty-to-notify (38 U.S.C.A. § 5103(a)). Considering the decisions of the Court in Pelegrini and Mayfield, the Board finds that the requirements of the VCAA have been satisfied in this matter, as discussed below. In a January 2000 letter, the RO informed the veteran of the information needed to substantiate a claim for PTSD based upon personal assault. In a March 2001 letter, the RO informed the appellant that her claim for PTSD was denied on the basis that the disorder was not incurred in or caused by her military service. In an October 2004 letter, the RO again advised the veteran of the information needed to substantiate her claim. In her notice of disagreement filed in October 2001, the veteran contended essentially that during the 1970s and 1980s, it was inappropriate for a female to report sexual harassment in the military and that she did not know her alleged attacker's name. Her basis for that assertion was that she was so traumatized by her assault that she "mentally blocked out [her attacker's] name". She reiterated this argument in her substantive appeal, on a VA Form 9, dated in June 2002. The RO issued a detailed May 2002 statement of the case (SOC) and October 2002 supplemental statement of the case (SSOC), in which she and her representative were advised of all the pertinent laws and regulations, including those regarding service connection for PTSD. We therefore believe that appropriate notice has been given in this case. The Board notes, in addition, that a substantial body of evidence was developed with respect to the appellant's claim, and that the SOC and SSOC issued by the RO clarified what evidence would be required to establish her claim. The appellant responded to the RO's communications with additional evidence and argument, thus curing (or rendering harmless) any previous omissions. Further, the claims file reflects that the May 2002 SOC contained pertinent language from the new reasonable doubt and duty-to-assist regulations codified at 38 C.F.R. §§ 3.102 and 3.159 (2004). See Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). All the above notice documents must be read in the context of prior, relatively contemporaneous communications from the RO. See Mayfield, supra, at 125. The Board concludes that the notifications received by the appellant adequately complied with the VCAA and subsequent interpretive authority, and that she has not been prejudiced in any way by the notice and assistance provided by the RO. See Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993); VAOPGCPREC 16-92 (57 Fed. Reg. 49,747 (1992)). Likewise, it appears that all obtainable evidence identified by the appellant relative to her claim has been obtained and associated with the claims file, and that neither she nor her representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. Thus, for these reasons, any failure in the timing or language of VCAA notice by the RO constituted harmless error. Accordingly, we find that VA has satisfied its duty to assist the appellant in apprising her as to the evidence needed, and in obtaining evidence pertaining to her claim, under both former law and the VCAA. The Board, therefore, finds that no useful purpose would be served in remanding this matter again for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the appellant. The Court of Appeals for Veterans Claims has held that such remands are to be avoided. See Winters v. West, 12 Vet. App. 203 (1999) (en banc), vacated on other grounds sub nom. Winters v. Gober, 219 F.3d 1375 (Fed. Cir. 2000); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In fact, the Court has stated, "The VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims." Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc). It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2004). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. B. Discussion Pursuant to 38 U.S.C.A. §§ 1110 and 1131, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by service. As to psychiatric disorders, even if there is no record of a psychosis in service, its incurrence in service will be presumed if the disease was manifest to a compensable degree within one year after service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.307, 3.309 (2004). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. Id. "A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). When no pre-existing condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. See 38 U.S.C.A. §§ 1111, 1137. The burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both pre-existing and not aggravated by service. See Wagner v. Principi, 370 F.3d. 1089 (Fed. Cir. 2004). VAOPGCPREC 3-2003. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. See 38 U.S.C.A. § 1153 (West 2002); Wagner, supra. If this burden is met, then the veteran is not entitled to service- connected benefits. See Wagner. However, if the Government fails to rebut the presumption of soundness under 38 U.S.C.A. § 1111, the veteran's claim is one for incurrence in service. Id. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322 (2004). On the other hand, if a pre-existing disorder is noted upon entry into service, a veteran cannot bring a claim for incurrence in service for that disorder, but a veteran may bring a claim for service-connected aggravation of that disorder. See 38 U.S.C.A. § 1153 (West 2002); Wagner. In that case, 38 U.S.C.A. § 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C.A. § 1153 arises, the burden shifts to the Government to show a lack of aggravation by establishing that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; see also Jensen, 19 F.3d at 1417; 38 C.F.R. § 3.306 (2004). First, the veteran has contended that service connection should be granted for an acquired psychiatric disorder, variously diagnosed as major depression, with delusional features. Although the evidence shows that the veteran currently has major depressive disorder with psychotic/delusional features, no competent medical evidence has been submitted to show that this disability is related to service or any incident thereof. On the other hand, the record reflects that her psychiatric examinations were normal on separation from service in April 1980 and in September 1982, and the first post-service evidence of record of an anxiety disorder was in 1997, more than 15 years after the veteran's separation from service. In June 2000, a VA examiner diagnosed anxiety and major depressive disorder, but questioned whether the veteran's social and industrial impairment was based solely on service-connected incidents. Moreover, two psychiatric examiners (Dr. D. in June 1999 and the August 2002) concluded that the veteran's diagnosed psychiatric disorder was not related to service. It is significant to note that, in August 2002, the VA examiner reviewed the veteran's medical records and examined her, and was unable to link the veteran's present mental status with her service time. In summary, no medical opinion or other medical evidence relating the veteran's acquired psychiatric disorder, currently diagnosed as major depression, with delusional features, to service or any incident of service has been presented. Second, the veteran also seeks service connection for PTSD. Establishing service connection for PTSD requires (1) a current medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304(f); Anglin v. West, 11 Vet. App. 361, 367 (1998); Gaines v. West, 11 Vet. App. 353, 357 (1998), Cohen v. Brown, 10 Vet. App. 128, 138 (1997); Suozzi v. Brown, 10 Vet. App. 307 (1997). The diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, of the American Psychiatric Association (DSM-IV). See generally Cohen v. Brown, supra; 38 C.F.R. § 4.125 (2004). In a PTSD claim, the evidence required to support the occurrence of an in-service stressor varies "depending on whether or not the veteran was 'engaged in combat with the enemy'. . . . Where . . . VA determines that the veteran did not engage in combat with the enemy . . . the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor." See Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The requisite additional evidence may be obtained from sources other than the veteran's service medical records. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996), aff'd, 124 F.3d 228 (Fed. Cir. 1997) (table); see also Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996); Doran v. Brown, 6 Vet. App. 283 (1994); Zarycki v. Brown, 6 Vet. App. at 98. Prior to March 7, 1997, governing regulations provided that service connection for PTSD required medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in- service stressor. If the claimed stressor was related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation would be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(f) (1996). However, on June 18, 1999, and retroactive to March 7, 1997, that regulation was amended to read as follows: Service connection for [PTSD] requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; 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 that 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. If the evidence establishes that the veteran was a prisoner-of-war under the provisions of § 3.1(y) of this part and the claimed stressor is related to that prisoner-of- war experience, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions and hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in- service stressor. 64 Fed. Reg. 32,807 (June 18, 1999), now codified at 38 C.F.R. § 3.304(f) (2004) (effective March 7, 1997). That amendment implemented the Cohen decision, which had held that 38 C.F.R. § 3.304(f) did not adequately reflect the law of the governing statute, 38 U.S.C.A. § 1154(b). The effective date of the amendment was March 7, 1997, the date the Cohen decision was issued by the Court. More recently, section 3.304(f) was again amended, with specific regard to PTSD claims based upon personal assault. The regulation now reads: Service connection for [PTSD] requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; 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. Although service connection may be established based on other in-service stressors, the following provisions apply for specified in- service stressors as set forth below: (1) If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that 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. (2) If the evidence establishes that the veteran was a prisoner-of-war under the provisions of § 3.1(y) of this part and the claimed stressor is related to that prisoner-of- war experience, 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. (3) If a [PTSD] claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a [PTSD] claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 67 Fed. Reg. 10,330 (March 7, 2002), codified at 38 C.F.R. § 3.304(f). The effective date of the amendment was March 7, 2002, the date of its issuance as a final rule. See YR v. West, 11 Vet. App. 393, 397-399 (1998) (credible evidence is not limited to service department records and can be obtained from any source). Where a law or regulation changes after a claim has been filed, but before the administrative and/or appeal process has been concluded, both the old and new versions must be considered. See VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3-2000 (Apr. 10, 2000). When amended regulations expressly state an effective date and do not include any provision for retroactive applicability, application of the revised regulations prior to the stated effective date is precluded. See 38 U.S.C.A. § 5110(g) (West 2002); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997); VAOPGCPREC 3-2000 (April 10, 2000); VAOPGCPREC 7-2003 (Nov. 19, 2003); 38 C.F.R. § 3.114(a) (2004); see also Fischer v. West, 11 Vet. App. 121, 123 (1998). Here, we observe that the RO, in its discussion of PTSD in the March 2001 rating decision and May 2002 SOC, referred to the obsolete, "definitive diagnosis" version of the regulation. If the present case turned upon the diagnosis, we might be compelled to remand this issue again for the RO to reconsider the matter under the new regulation. However, because the Board is not directly questioning the diagnosis of PTSD, we believe that another remand would simply delay the resolution of this claim unnecessarily, with no benefit to the veteran. See Winters, Soyini, Sabonis, supra. Moreover, the 2002 amendment to section 3.304(f) also does not require further development of this case, because there is no unresolved factual issue as to the occurrence of the scenario that constitutes the claimed personal assault "stressor" in service. In fact, as will be discussed below, the available record is not referable to any complaint of or treatment for a sexual assault in service, and the veteran has not alluded to any additional information that would counter that lack of supportive evidence. The Board would note, at the outset, that the record reflects that some medical professionals have questioned whether the veteran has PTSD related to service. In June 1999, Dr. D. found she did not have PTSD and, in June 2000, a VA examiner reported she may have PTSD, but it was not clearly related to service and, in August 2002, a VA examiner said that the veteran did not meet the criteria for PTSD. However, as noted below, in September 2001, a VA psychologist reported treating the veteran for PTSD for more than a year. The record reveals that, during the course of her appeal, the veteran has described alleged stressors that caused her PTSD: that she was raped by a petty officer in July 1982 in a motel in [redacted], [redacted], while on liberty, and that she experienced repeated sexual harassment in service. When the veteran initially filed her claim, in March 1999, she submitted a statement of her alleged stressful events in service in which she reported that she was verbally abused in service. The Board notes that a February 1999 VA medical record indicates she reported both sexual harassment and verbal abuse in service. When examined by VA in June 1999, the veteran said that in the Army she was not allowed to work in her specialty as a boat operator because she was a woman. The Board notes that the veteran has also contended that she was the victim of sexual assault. She has said that an officer raped her while she was on active duty in 1982, and variously alleged that she experienced repeated sexual harassment in service. In her September 2001 notice of disagreement and June 2002 substantive appeal, she essentially reiterated the statements made in her March 1999 stressor statement. In May 2000, she told a VA health care professional that she was sexually abused as a child by her stepfather and later physically abused in service. In her 1999, 2001, 2002, and 2004 written statements, the veteran reported being raped by a petty officer who was her supervisor, but she was so traumatized that she blocked out his name. There has been a medical diagnosis of PTSD, attributed to the alleged stressor incidents, made by a VA psychologist at the VAMC in Prescott. Accordingly, the Board finds that there is some evidence of a stressor incident or incidents in service, evidence of a current disability, and also seemingly competent evidence that the current disability is a "residual" of the stressor experienced in service. With that in mind, the Board must review the claim on its merits, account for the evidence that it finds to be persuasive and unpersuasive, and provide reasoned analysis for rejecting evidence submitted by or on behalf of the claimant. Gilbert, supra. For a claim to be denied on its merits, the evidence must preponderate against the claim. Alemany v. Brown, supra. As noted above, the Board is not directly questioning the diagnosis of PTSD in this claim. However, by law, the evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy." See Gaines v. West, 11 Vet. App. 353 (1998) (Board must make a specific finding as to whether the veteran engaged in combat). If the claimed stressor is not combat related, the veteran's lay testimony, by itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain credible supporting evidence from any source that corroborates the veteran's testimony or statements. YR v. West, 11 Vet. App. at 397; Cohen, 10 Vet. App. at 147. In the particular case of claimed personal assault, VA has established special procedures for evidentiary development. See VA Adjudication Procedure Manual M21-1 (hereinafter Manual M21-1), Part III, paragraph 5.14c (Feb. 20, 1996) (substantially enlarging on the former Manual M21-1, Part III, paragraph 7.47c(2) (Oct. 11, 1995)). These procedures take into account the difficulty establishing the occurrence of the stressor through standard evidence, and the need for development of alternate sources of evidence. The provisions of Manual M21-1 dealing with PTSD are substantive rules that are the equivalent of VA regulations; VA is therefore required to follow these provisions. Patton v. West, 12 Vet. App. 272, 277 (1999); YR, supra, 11 Vet. App. at 398-99; Cohen, 10 Vet. App. at 139. Moreover, the 2002 amendments to 38 C.F.R. § 3.304(f), quoted above, have augmented the substantive law pertaining to such claims. The final requirement of 38 C.F.R. § 3.304(f) for service connection of PTSD is medical evidence of a nexus between the claimed in-service stressor and the current disability. In cases of claimed personal assault, VA recognizes that some evidence may require interpretation by a clinician to establish a relationship to the diagnosis, per Manual M21-1, Part III, paragraph 5.14c(9). Accordingly, the general rule that post-service medical nexus evidence cannot be used to establish the occurrence of the stressor is not operative in such cases. Patton, 12 Vet. App. at 280. See Cohen, 10 Vet. App. at 145; Moreau, 9 Vet. App. at 396. The starting point for any determination with regard to PTSD is whether there is a "stressor." Under all versions of the controlling regulation, there must be credible supporting evidence that the claimed in-service stressor(s) actually occurred. 38 C.F.R. § 3.304(f). The question of whether the veteran was exposed to a stressor in service is a factual determination, and VA adjudicators are not bound to accept such statements simply because treating medical providers have done so. Wood v. Derwinski, supra, Wilson v. Derwinski, 2 Vet. App. 614 (1992). 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 v. Brown, 6 Vet. App. 91 (1993). As the veteran does not allege that she engaged in combat, and as her reported stressors are not related to combat, her assertions, standing alone, cannot, as a matter of law, provide evidence to establish that an in-service event claimed as a stressor occurred. See Dizoglio v. Brown, 9 Vet. App. 163 (1996); West v. Brown, 7 Vet. App. 70, 76 (1994). Furthermore, service department records must support, and not contradict, the claimant's testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). This does not mean that she cannot establish that the alleged in-service events occurred; it only means that other "credible supporting evidence" from some source is necessary. See Cohen. Since there is a diagnosis of PTSD here, it must be determined whether there is credible supporting evidence of the veteran's alleged stressor, i.e., whether service records or other independent credible evidence corroborates the alleged stressor. See Dizolgio, supra. The Court of Appeals for Veterans Claims has held repeatedly that, where there is a current diagnosis of PTSD, it must be presumed that the physician(s) making the diagnosis accepted the sufficiency of the in-service stressor(s). Nevertheless, since the diagnostician does not generally have firsthand knowledge of whether a stressor actually occurred, credible evidence is required to verify that element. Pentecost v. Principi, 16 Vet. App.124 (2002). Based upon a review of the entire record in this case, and in view of the factors discussed above, the Board finds that the evidence of record has not corroborated the veteran's allegation of a rape in service. The veteran initially maintained that she was raped in a motel, by a petty officer whose identity she cannot recall, while on liberty in [redacted], [redacted], on or about [redacted], although she has provided no specifics of the alleged event. The record also contains a 2001 statement from a VA psychologist to the effect that the veteran reported being sexually assaulted in service. Contravening the above evidence is the fact that the August 2002 VA examiner questioned the reliability of veteran's perceptions and memories of the alleged rape due to her gross intoxication, and noted the limited report of any rape. More importantly, the veteran has failed to provide the RO with any specific information upon which her allegation of rape in [redacted], [redacted], could be verified. In its January 2000 letter to the veteran, the RO requested that she provide the specifics of her alleged traumatic event, but she failed to respond to the RO's requests. See Wood v. Derwinski, supra. Notwithstanding the absence of medical records, and giving the veteran the benefit of the doubt, nevertheless, her description of her stressful events in service has been vague, to say the least. In June 1999, when examined by Dr. D., she described being raped in service, but did not report childhood sexual abuse, or rape, but in June 2000, the VA examiner noted that she reported that she was a victim of childhood sexual or physical abuse. In August 2002, she described child sexual molestation that she told the VA examiner was "normal" for her regional culture, and that she did not recall being disturbed by it. Moreover, her failure to respond to the RO's requests for specific information regarding her stressful event leaves the Board with virtually no factual information upon which to rely regarding the alleged assault. Likewise, medical statements which attempt to accept a claimant's reports as credible and then relate a diagnosis of PTSD to events experienced in service do not constitute the requisite credible evidence of a stressor. Moreau v. Brown, 9 Vet. App. at 389. As noted above, several VA treatment reports reflect that the examiners have indicated that the veteran's current diagnosed psychiatric disorders, particularly PTSD, were due to sexual assault/rape. Clearly, those treating psychiatric physicians and psychologists did not undertake review of the veteran's service records, but based their premises of in-service sexual assault solely upon the veteran's statements to them. The filtering of the veteran's account of her military service through her physician does not transform her account into competent medical evidence, or an accurate account of those experiences, merely because the transcriber happens to be a medical professional. See Leshore v. Brown, 8 Vet. App. 409 (1995). Moreover, with regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that a post-service reference to injuries sustained in service, without a review of service medical records, is not competent medical evidence. Grover v. West, 12 Vet. App. 109, 112 (1999). A medical opinion based upon speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the claimant's history, and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Further, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998); LeShore v. Brown, supra. In fact, in June 1999, Dr. D. concluded that the veteran did not have PTSD, although in June 2000, the VA examiner found she might have elements of PTSD, but they were not clearly related to service although, in August 2002, the VA examiner opined that the criteria for PTSD were not met. As a layperson, the veteran is not competent to render a medical opinion in this regard. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). Accordingly, the veteran is not entitled to service connection for PTSD under the theory that it resulted from unverified, vaguely reported stressors during service. In light of the foregoing, the Board finds that the record does not support the veteran's assertion that she was raped during her second period of active service. Thus, although the foundation for the diagnosis of PTSD in this case was the veteran's account of having been raped, we must conclude that the claimed stressor has not been satisfactorily established as having occurred. The veteran may very well consider events that occurred in conjunction with her alleged sexual events in service to be stressful, but she has failed to provide even one factual detail of the alleged events on which to base her claim, other than a specific description of an alleged sexual assault during her second period of service. Thus, while the veteran does have a diagnosis of PTSD based upon her purported in-service stressor, that stressor is not shown by satisfactory evidence to have occurred. The Board appreciates the testimony offered at her Travel Board hearing before the undersigned. With all due respect to the veteran, we find that her oral and written statements in support of her claim are, thus, unsubstantiated and are of little evidentiary weight. Having so concluded, the Board finds that the preponderance of the credible evidence is against the claim, and that neither a VA psychiatric examination nor further interpretation by a clinician of the in-service symptoms/behavior is necessary. See M21-1, Part III, 5.14(c); Patton v. West, supra at 280. We have considered the doctrine of reasonable doubt. Under that doctrine, when there is an approximate balance between evidence for and against a claim, the evidence is in equipoise, there is said to be a reasonable doubt, and the benefit of such doubt is given to the claimant. 38 U.S.C.A. § 5107(b); see Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); 38 C.F.R. § 3.102. However, when the evidence for and against a claim is not in equipoise, then there is a preponderance of evidence either for or against the claim, there is no reasonable doubt, and the doctrine is inapplicable. Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). Since the objective medical evidence preponderates against the veteran's claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (old and new versions); Gilbert v. Derwinski, supra. Based upon the evidence of record, service connection for an acquired psychiatric disorder, to include PTSD, must be denied. ORDER Service connection for an acquired psychiatric disorder, to include PTSD, is denied. ___________________________ ANDREW J. MULLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs