Citation Nr: 1331925 Decision Date: 10/03/13 Archive Date: 10/07/13 DOCKET NO. 07-29 749 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and bipolar disorder. 2. Whether new and material evidence has been received to reopen a claim of service connection for a disability manifested by tremors as secondary to bipolar disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from February 1961 to February 1964. This case comes to the Board of Veterans' Appeals (Board) on appeal of a February 2007 rating decision of the Phoenix, Arizona, Regional Office (RO) of the Department of Veterans Affairs (VA), which, in pertinent part, denied reopening claims of service connection for an acquired psychiatric disability, including PTSD and bipolar disorder; a disability manifested by tremors, as secondary to bipolar disorder; and a dental disability. A hearing was held before a Decision Review Officer at the RO in September 2007. A copy of the transcript has been associated the claims folder. The case was before the Board in March 2011, at which time it was found that new and material evidence had been received to reopen claims of service connection for an acquired psychiatric disability, including PTSD and bipolar disorder. At that time, the Board denied reopening the claim of service connection for a dental disability, and the matters related to service connection for an acquired psychiatric disorder and reopening the claim of intertwined issue of a disability manifested by tremors as secondary to bipolar disorder were remanded by the RO to obtain additional treatment records, arrange for a VA examination and for de novo review of the reopened claim. This has been accomplished and the case is now returned for appellate consideration. FINDINGS OF FACT 1. An acquired psychiatric disability, including PTSD and bipolar disorder, did not have its clinical onset in service and is not otherwise related to active duty. 2. Service connection for a disability manifested by tremors was denied by the RO in a May 2004 rating action. The Veteran was notified of this action and of his appellate rights, but did not file a timely appeal. 3. Since the May 2004 decision denying service connection for a disability manifested by tremors, the additional evidence, not previously considered, is cumulative and does not relate to an unestablished fact necessary to substantiate the claim or raise a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. An acquired psychiatric disability, including PTSD and a bipolar disorder, was not incurred or aggravated in service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The additional evidence received subsequent to the May 2004 decision of the RO that denied service connection for a disability manifested by tremors is not new and material; thus, service connection for this disability is not reopened, and the May 2004 RO decision remains final. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In Kent v. Nicholson, 20 Vet. App. 1 (2006), the United States Court of Appeals for Veterans Claims (Court) held that in a claim to reopen a previously finally denied claim, VCAA notice must notify the claimant of the meaning of new and material evidence and of what evidence and information (1) is necessary to reopen the claim; (2) is necessary to substantiate each element of the underlying service connection claim; and (3) is specifically required to substantiate the element or elements needed for service connection that were found insufficient in the prior final denial on the merits. The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. A May 2006 letter provided notice in accordance with Kent, explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. A March 2006 letter informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. As to the claim of service connection for a psychiatric disability, including PTSD and bipolar disorder, the Board finds that all notification and development action needed to arrive at a decision has been accomplished. Contrary to the contentions of the Veteran's representative in the appellate brief, the May 2006 notification later provided the Veteran with notification of the information and evidence needed to substantiate his claim for service connection for PTSD, including alternative sources that can be utilized to substantiate the Veteran's non-combat related stressor. Consequently, a remand of this issue for further notification of how to substantiate the claim is not necessary. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. This includes VA and private treatment records, statements from the Veteran, Social Security Administration (SSA) records, and service personnel records. Significantly, the Veteran has not otherwise alleged that there are any outstanding medical records probative of his claims on appeal that need to be obtained. Thus, the Board finds that VA has properly assisted the Veteran in obtaining any relevant evidence. Additionally, the Veteran was afforded a VA examination in April 2011, the report of which is of record. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examination relative to the acquired psychiatric disorder claim is sufficient, as it is predicated on consideration of the private and VA treatment records in the Veteran's claims file, as well as specific examination findings. The VA examiner considered the statements of the Veteran and provided a rationale for the findings made, relying on and citing to the records reviewed. While it was noted by the Veteran's representative that the examiner did not actually review the record prior to examination of the Veteran, the records were reviewed prior to promulgation of the examination report. The Board finds that this is sufficient to meet the orders contained in the March 2011 remand. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination concerning the acquired psychiatric disability claim has been met. 38 C.F.R. § 3.159(c)(4). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). 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. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The provisions of 38 C.F.R. § 3.303(b) do not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F.3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). To establish entitlement to service connection for PTSD, the record must contain the following: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) ; see also Cohen v. Brown, 10 Vet. App. 128 (1997). If the alleged stressor is not combat-related, then a veteran's lay testimony, in and of itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates his testimony or statements. See Zarycki v. Brown, 6 Vet. App. 91 (1993); Cohen 10 Vet. App. at 128; Moreau v. Brown, 9 Vet. App. 389, 395 (1996). The Board notes that, with regard to stressor verification, the VA regulation at 38 C.F.R. § 3.304(f) was recently amended to liberalize the requirement of verification or corroboration of a veteran's claimed in-service stressor events in a PTSD claim. 38 C.F.R. § 3.304(f)(3), as added in 75 Fed. Reg. 39,843-852 (July 13, 2010). However these revisions do not pertain to claims for PTSD that, as here, are predicated on personal assault, combat, or prisoner of war (POW) experience since these type of claims already have their special provisions for establishing the occurrence of a stressor in these other type situations. The only notable change for claims predicated on personal assault was the redesignation of this type of claim from subpart (f)(4) to (f)(5). Under 38 C.F.R. § 3.304(f)(5), evidence of behavior changes following the claimed in-service assault may constitute credible supporting evidence of the stressor. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to, a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA may submit any evidence that it received to an appropriate mental health professional for an opinion as to whether it indicates that a personal assault occurred. With regard to personal assault cases, the Court has held that "VA has provided special evidentiary development procedures, including the interpretation of behavior changes by a clinician and interpretation in relation to a medical diagnosis." Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996) (citing VA Adjudication Procedure Manual M21-1 (M21-1), Part III, 5.14c (8)-(9)) (later redesignated as Part VI, 11.38b(2), and now rescinded), aff'd 124 F.3d 228 (Fed. Cir 1997). The provisions of M21-1 (regarding special evidentiary procedures for PTSD claims based on personal assault) are substantive rules that are equivalent to VA regulations. YR v. West, 11 Vet. App. 393 (1998); Cohen v. Brown, 10 Vet. App. 128 (1997). The Board notes that the aforementioned provisions of M21-1 have been rescinded and reissued as amended in a manual rewrite (MR). See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. D, Para. 17 (2006), entitled "Developing Claims for Service Connection for PTSD Based on Personal Trauma." Acquired Psychiatric Disorder, Including PTSD and Bipolar Disorder The Veteran asserts that he developed PTSD that began during his military service following a sexual assault by a Master Sergeant. See, e.g., the Veteran's statement received by VA in November 2003 and February 2007. Specifically, the Veteran described an incidents of sexual molestation by a superior officer. He stated that he did report the incident to the unit chaplain, but that he was told that he had "best think twice before you ever again accuse a Master Sergeant of something he would never do." Id. For the reasons set forth below, the Board concludes that service connection is not warranted. Review of the Veteran's STRs show no complaints or manifestations of a psychiatric disorder. On examination for separation from service, the report of medical history form shows that he has not had frequent or terrifying nightmares, depression, excess worry, or any other complaints of psychiatric symptoms. (The form actually shows that the Veteran answered "yes" to some of these symptoms, but crossed out his answer and then checked the boxes for "no.") His service personnel folder does not include references to instances such as a request for a transfer to another military duty assignment, deterioration in work performance, substance abuse; or unexplained economic or social behavior changes. The service documents were absent any documentation of sexual assault or psychological complaints. Post-service treatment records show that the Veteran was initially treated for psychiatric complaints, diagnosed as major depression, single episode, in May 1998. At that time, the Veteran reported that he had feelings of depression since the unexpected loss of his job. Other stressors included mounting financial problems as a result of his job loss and a new marriage that had occurred one week prior to his job loss. It was historically reported that the Veteran had briefly sought therapy in the mid 1980's after divorcing his first wife. It was noted that this was his first experience with psychotropic medications. A summary of treatment received from a private facility in February 2004 shows that the Veteran was treated from June 1996 until August 1999. It was noted that the Veteran's symptoms had seemed to have disappeared by September 1998, but that in March 1999 he again sought treatment and was diagnosed as having bipolar disorder. The summary included references to the Veteran's willingness to take responsibility for his actions and to heal himself from "innumerable past hurts." These were said to include emotional abuse by his mother; having to take total responsibility for the family farm as the oldest of the children while his father worked elsewhere; being emotionally, physically and verbally abused by his father; enduring several traumas at a young age that included almost freezing to death after rescuing 18 school children following a school bus accident in a snowstorm, being twice hit by trains, being the first on the scene of a fatal accident, being shot at age 6, having a head injury in a farm accident with loss of consciousness for 8 days, and having a long-term love affair with his mother's best friend beginning at the age of 14. In March 2003, the Veteran again sought psychiatric treatment at a private facility. The pertinent diagnosis at that time was bipolar disorder. Treatment records show no initial complaints relative to psychiatric symptoms as a result of sexual trauma during his period of active duty in the early 1960's, but in private treatment records received pursuant to the recent remand by the Board, it is noted that he reported an episode of sexual molestation during counseling in October 2003. In addition, in a VA outpatient treatment consultation in October 2003, he reported symptoms of anxiety and panic attacks that he believed may have started while he was in the military. At that time, he reported having been sexually abused by a master sergeant. In an August 2006 report of a psychological evaluation, the Veteran was given diagnoses of bipolar disorder, PTSD and alcohol abuse by history. The psychiatric history included the Veteran's report of evidence of depression and anxiety during military service that occurred after he had been sexually molested by his superior. He related that the sexual molestations were under the color of authority. This caused the Veteran to become hopeless, angry, physically aggressive, less confident, increased alcohol intake and increased promiscuity. The psychiatrist linked the Veteran's disabilities to military service for several reasons, including the fact that the Veteran was without evidence of mood or anxiety or substance abuse disorders prior to military service; a worsening of alcohol abuse; demonstration of anxiety, panic attacks, depression while in service; and evolution of the anxiety features into residual presentation of PTSD. An examination was conducted by VA in November 2006. At that time, the Veteran's chief complaints were of panic attacks. The Veteran reported on his military history and stated that he "liked the military while I was in it." The examiner reviewed the Veteran's stressor letter that included the report of sexual molestation, but noted that there were no objective or subjective complaints of a mental health condition at the time of separation from service. The examiner noted other treatment summaries in the claims folder that included references to a number of traumas reported by the Veteran, including almost freezing to death, being shot at age six, and suffering a head injury resulting in an eight day period of unconsciousness. After complete examination, the diagnoses were bipolar disorder and PTSD. The examiner noted that, while the Veteran did self-report a number of stressors, he did not report any significant problems with persistent re-experiencing of those stressors on this examination. The Veteran only reported panic attacks as his principle problem, but did not carry a current diagnosis of a panic disorder. An examination was conducted by VA in April 2011. At that time, the Veteran's psychiatric treatment notes were thoroughly reviewed. It was noted that in October 2003, it was written that the Veteran had manifested a cycling mood disorder for many years that was first diagnosed in Pennsylvania in 1998. He also had symptoms compatible with PTSD related to military sexual trauma. Medical history included the STRs and service personnel records negative for any mental health diagnosis, psychiatric symptoms, episodes of violence, or other problematic behaviors; a treatment summary detailing treatment from June 1996 until August 1999 showing treatment for marital problems and depression that eventually included treatment for bipolar disorder; treatment in Phoenix beginning in 2003 for a bipolar disorder; and an August 2006 evaluation outlining the Veteran's psychosocial history, psychiatric symptoms and providing a link between these psychiatric symptoms and service. During the evaluation, the Veteran reported PTSD symptoms that had been with him for most of his adult life. It was noted that he had reported to other treatment providers that he experienced a number of traumas throughout his life, yet stated now that the PTSD had started post military. The diagnoses were PTSD and bipolar disorder. The examiner noted all of the traumas reported by the Veteran, including the sexual molestation during service, almost freezing to death, being shot at age six, being unconscious for eight days, being abused by his father, and having a long-term affair with his mother's best friend at age 14. The Veteran also described symptoms consistent with a bipolar disorder that were first noted nearly 40 years after service so that a connection with military service appeared to be speculative. Regarding the diagnosis of PTSD, the examiner was unable to render an opinion regarding a relationship with service as there were no psychiatric symptoms in the STRs or personnel records and the 2006 VA examination noted that the Veteran did not report re-living of the reported trauma. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A medical opinion based on an inaccurate factual premise is not probative. See 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. See Miller v. West, 11 Vet. App. 345, 348 (1998); see also Leshore v. Brown, 8 Vet. App. 409 (1995). The Board finds the April 2011 VA medical examination report probative as to the question of diagnosis as it appears to have been based upon a thorough review of the record and a thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Crucially, the April 2011 VA examiner concluded that the Veteran did not have PTSD that could be attributed to the sexual trauma alleged to have taken place during service. The rationale was substantial, thorough, and based on the overall record. Considering all evidence of record, the Board finds that the Veteran is not entitled to service connection for PTSD, to include as due to personal or sexual assault in service. Although the private medical care provider in 2006 diagnosed PTSD based on an alleged stressor during service, VA is not required to grant service connection just because a health care professional accepts a claimant's description of experiences during military service as credible and diagnoses PTSD. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). While the adequacy of a reported stressor to cause PTSD is a medical determination, the existence or occurrence of the event alleged as a stressor that caused PTSD is an adjudicative determination. Zarycki 6 Vet. App. at 91. The Board notes that the Veteran is competent to report that he was sexually assaulted during service, because such alleged incidents are factual in nature and would be within his realm of personal experience. Barr, 21 Vet. App. at 307; Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). He is also competent to report observable symptoms of a mental health disorder after the alleged in-service incident, and treatment for such symptoms. Jandreau, 492 F.3d at 1376-77. VA adjudicators must, however, determine whether competent evidence is credible, and weigh the lay and medical evidence submitted. VA may not determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence, but the absence of contemporaneous medical evidence may be weighed against the lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In determining credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). VA may not discredit testimony simply because the veteran is an interested party and stands to gain monetary benefits, but personal interest may affect the credibility. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Here, the Board finds the Veteran to be not credible with regard to the occurrence of the alleged sexual assault, as there are numerous prior statements regarding the onset of his psychiatric symptoms that do not include reference to the sexual assault. Thus his statements are inconsistent. Specifically, as indicated above, the Veteran initially gave numerous stressors to private examiners when he was first treated in the 1990's or when initially treated in 2003. It was not until after he had submitted his initial claim for compensation benefits in July 2003 that the description of sexual assault during service was made. This is not to say that the assault did not occur, but that there is not credible verification that can permit the Board to grant the benefit. Specifically, there are no indications of behavioral changes in service after the alleged stressor events. The Veteran's service personnel records, including performance evaluations, do not document any behavioral problems during his military service. Crucially, as indicated above, for a non-combat stressor, in order to establish service connection for PTSD, there must be competent and credible evidence of an in-service stressor, and a current diagnosis under the DSM-IV standards which is based upon that stressor. The VA examiners in 2006 and 2011 found no evidence that the Veteran's PTSD was the result of an in-service stressor. Moreover while VA and private providers appear to have diagnosed PTSD based on the Veteran's reported stressor during service, the stressor has not been verified or corroborated. Regarding the claim of service connection for a bipolar disorder, it is noted that this disability was not manifested during service or in the years immediately thereafter. A bipolar disorder was first demonstrated over 30 years after the Veteran's separation from service. The absence of clinical treatment records for approximately 35 years after active duty is probative evidence against continuity of symptoms since service. Mense v. Derwinski, 1 Vet. App. 354 (1991). While the private physician related the Veteran's psychiatric symptoms to sexual assault during service, as noted, the Board has not found the description of the sexual assault to be wholly credible. As such, there is no basis for establishing service connection for bipolar disorder. Accordingly, the preponderance of the evidence is against this service connection claim. The benefit-of-the-doubt rule does not apply, and the Veteran's claim for service connection for an acquired psychiatric disorder, including PTSD and bipolar disorder, is denied. See 38 U.S.C.A § 5107 (West 2002 & Supp. 2012). Tremors Service connection for a disability manifested by tremors was previously denied by the RO in a May 2004 rating decision. The Veteran did not appeal this determination. In such cases, it must first be determined whether new and material evidence has been received such that the claim may now be reopened. 38 U.S.C.A. §§ 5108, 7105; Manio v. Derwinski, 1 Vet. App. 140 (1991). A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. The evidence submitted to reopen a claim is presumed to be true for the purpose of determining whether new and material evidence has been received, without regard to other evidence of record. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). Evidence of record at the time of the May 2004 RO decision that denied service connection for a disability manifested by tremors as secondary to a bipolar disorder included the Veteran's STRs, which were negative for evidence of tremors; and VA and private medical records of treatment for psychiatric disabilities. Service connection for a disability manifested by tremors was essentially denied because the Veteran's claim was that this disability was secondary to a bipolar disorder for which service connection was not in effect. In his current application to reopen the claim of service connection for a disability manifested by tremors, the Veteran again contends that service connection for tremors is warranted as being proximately due to or the result of a service-connected disease or injury, specifically bipolar disorder. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). Evidence received subsequent to the May 2004 rating decision includes the Veteran's testimony at the hearing on appeal in October 2006, which was to the effect that he has a disability manifested by tremors as a result of bipolar disorder; and additional private and VA treatment records, including VA compensation examinations in November 2006 and April 2011. The hearing testimony essentially duplicates the contentions advanced in May 2004 and the additional treatment records and examinations consist primarily of records of treatment many years after service that do not indicate in any way that a disability manifested by tremors is related to a service-connected disability. Such evidence is not new and material evidence upon which the claim may be reopened. Cox v. Brown, 5 Vet. App. 95 (1993). Service connection is currently in effect for a right wrist scar and a scar, residuals of a head injury. Both disabilities are rated noncompensable (zero percent). The Board finds no basis for the establishment of secondary service connection for a disability manifested by tremors as a result of either of the Veteran's service-connected disabilities. Significantly, as described above, service connection is not in effect for bipolar disorder, the disability contended by the Veteran as causing his tremors. Under these circumstances, the Board finds that new and material evidence to reopen a claim of service connection for a disability manifested by tremors has not been submitted and the claim remains denied. ORDER Service connection for an acquired psychiatric disability, including PTSD and bipolar disorder, is denied. New and material evidence having not been submitted, the application to reopen the claim of service connection for a disability manifested by tremors is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs