Citation Nr: 1332408 Decision Date: 10/18/13 Archive Date: 10/24/13 DOCKET NO. 05-19 455 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a psychiatric disorder to include bipolar disorder as well as post-traumatic stress disorder (PTSD), also claimed as secondary to military sexual trauma (MST). 2. Entitlement to service connection for a cervical spine disorder. 4. Entitlement to service connection for residuals of nasal fracture. 4. Entitlement to service connection for headaches. 5. Entitlement to service connection for a gastrointestinal disorder. REPRESENTATION Appellant represented by: Susan L. Carpenter, Attorney WITNESSES AT HEARING ON APPEAL Veteran and his parents ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served in the National Guard from March 1981 to June 1992 with various periods of active duty for training (ADT), inactive duty for training (IDT), to include confirmed periods of active duty from June 1981 to December 1981 and again from October 1991 to June 1992. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran had a hearing before the Board in February 2009 and the transcript is of record. The case was brought before the Board in March 2008 and August 2009, at which times the claims were remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his claims, to include affording him VA examinations. In June 2011, the Board adjudicated some of the issues on appeal and remanded the issues currently remaining, as listed on the front page of this decision. The Veteran, thereafter, changed representation to a private attorney, also listed on the front page of this decision. It is noted that additional evidence, consisting of VA mental health treatment records, was added to the record in July 2012. Given the favorable decision, with respect to service connection for a psychiatric disability, the Board need not refer this evidence to the RO for initial consideration. FINDINGS OF FACT 1. PTSD, with associated diagnoses to include a bipolar disorder, dysthymic disorder, chronic mood instability, depression, and anxiety, is attributable to service. 2. A cervical spine disorder is not attributable to service. 3. Residuals of nasal fracture are not attributable to service. 4. A headache disorder is not attributable to service. 5. A gastrointestinal disorder is not attributable to service. CONCLUSIONS OF LAW 1. PTSD with associated diagnoses to include a bipolar disorder, dysthymic disorder, chronic mood instability, depression, and anxiety, was incurred in active service. 38 U.S.C.A. § 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304(f) (2012). 2. A cervical spine disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 101, 106, 1101, 1110, 1131 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2012). 3. A nasal disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 101, 106, 1101, 1110, 1131 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2012). 4. A headache disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 101, 106, 1101, 1110, 1131 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2012). 5. A gastrointestinal disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 101, 106, 1101, 1110, 1131 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). So this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, this notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If, however, for whatever reason it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary notice and then readjudicating the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The U.S. Supreme Court has made clear that VCAA notice errors are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as the pleading party attacking the agency's decision, the Veteran, not VA, bears this burden of proof of establishing there is a VCAA notice error and, moreover, above and beyond this, that the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir., 2004). VCAA letters were sent in May 2006, October 2009, December 2009, June 2011, and October 2011. The letters, especially in combination, indicated the type of evidence and information needed to substantiate the claim and apprised the Veteran of the Veteran's and VA's respective responsibilities in obtaining this supporting evidence. The letters also notified the Veteran that a "downstream" disability rating and an effective date for the award of benefits would be assigned if service connection was granted, in compliance with Dingess. Regarding the duty to assist, VA also satisfied this obligation in terms of obtaining all potentially relevant evidence concerning these claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records (STRs), VA medical treatment records, and identified private medical records were obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Although medical records from West Point were sought, there are no available records per a finding of unavailability made in March 2009. There is no indication that any additional evidence, relevant to these claims, is available and not part of the record. The Veteran also was provided VA compensation examinations, including for medical nexus opinions concerning the etiology of the claimed disorders and their potential relationship with military service, as the Board directed when remanding these claims in August 2009 and June 2011. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The medical nexus opinions obtained are responsive to the determinative issue of causation, so additional examinations and opinions are not needed. 38 C.F.R. § 4.2. See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). And see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). The most recent examinations of record are adequate to address all pertinent concerns, as the record was reviewed for the relevant medical and other history, the Veteran examined, the findings reported in sufficient detail, and there was discussion of the underlying medical rationale, which is where most of the probative value of an opinion is derived. See Neives-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The VA examination reports are thorough and supported by the record. The records taken as a whole satisfy 38 C.F.R. § 3.326. Furthermore, in obtaining the additional medical evidence, the Board is satisfied there was compliance with this remand directive. See Stegall v. West, 11 Vet. App. 268 (1998) (indicating the Veteran is entitled, as a matter of law, to compliance with a remand directive and that the Board, itself, commits error in failing to ensure this compliance). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (discussing situations when it is acceptable to have "substantial", though not "exact", compliance with a remand directive). In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for disability resulting from disease or injury incurred during active duty for training (ADT), or injuries suffered during inactive duty training (IDT) to include when a cardiac arrest or a cerebrovascular accident occurs during such training. See 38 U.S.C.A. §§ 101(24), 106. Reserve and National Guard service generally means ADT and IDT. ADT is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. IDT includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year. These drills are deemed to be part-time training. Active military service includes active duty, any period of ADT during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of IDT during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C.A. § 1106; 38 C.F.R. § 3.6(a). Generally, an individual who has only Reserve or National Guard service (ADT or IDT with no active duty) is not a veteran as legally defined. In the service connection context, for example, this means that the presumption of soundness upon entry into service and the presumptive service connection provisions of 38 C.F.R. § 3.307, applicable to active duty, would not apply to ADT or IDT. 38 U.S.C.A. §§ 1111, 1112, 1137; 38 C.F.R. § 3.307. Thus, service connection on a presumptive basis is not available where the only service performed is ADT or IDT. See Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In addition, a psychosis will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board notes that 38 C.F.R. § 3.303(b) provides that with chronic diseases shows as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of cases, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. 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, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and the Department of Veterans Affairs regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). The U. S. Court of Appeals for the Federal Circuit (Federal Circuit) recently held that the regulation creating a presumption of service connection for "chronic diseases" manifesting during service and then again at any later date (38 C.F.R. § 3.303(b)), is only available to establish service connection for the "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). In the same case, the Federal Circuit clarified that the continuity of symptomatology language in § 3.303(b) also "restricts itself to chronic diseases" found in 38 C.F.R. § 3.309(a). Id. at 1335. With respect to the current appeal, this list includes psychoses. See 38 C.F.R. § 3.309(a). Walker held that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above. The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection or service connection via continuity of symptomatology. In this case, service connection is established, as discussed below, for PTSD, as an injury sustained by the Veteran during basic training which took place after he entered military service in June 1981. Thus, the Veteran has achieved "veteran" status. In addition, for his initial period during which basic training occurred, he is entitled to the VA presumptions. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). When, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As held in Davidson, section 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. See also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence" such as actual treatment records). In addition, the Veteran is competent to report the Veteran can observe and feel through the senses. See Layno. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Once evidence is determined to be competent, the Board must determine whether the evidence also is credible, as only then does it ultimately have probative value. See Layno (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). In this case, the Veteran had medical training as a medic during service. Thus, he may provide his medical opinion as well as his lay opinion, although both must be considered in the context of the entire record. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims ("the Court") similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing when he/she has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, aff'd per curiam, 78 F.3d 604(Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. PTSD 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. See 38 C.F.R. § 3.304(f). The following provisions apply to claims for service connection of PTSD diagnosed during service or based on the specified type of claimed stressor: (1) If the evidence establishes a diagnosis of PTSD during service and the claimed stressor is related to that service, 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 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. (3) If a stressor claimed by the Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. (4) 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. (5) 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 disorder 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. The Veteran's STRs are silent as to any complaints, treatment or diagnoses of psychiatric illness. Currently, the Veteran is diagnosed with numerous psychiatric conditions, to include PTSD, bipolar disorder, depression, and anxiety disorder. The Veteran claims he has PTSD and other psychiatric conditions primarily as a result of inservice MST. Specifically, the Veteran claims on July 4, 1981 he was physically attacked and forced to perform sexual acts with commanding officers after being in the military less than one month at basic training. The Veteran indicates he did not report the incident because he was scared of reprimand. The Veteran also contends he has experienced symptoms of nightmares, fear and panic attacks since a 1984 motor vehicle accident (MVA). The occurrence of this accident was confirmed by the Veteran's father as well as in a letter from another service member in his personnel file. A review of the medical records shows that a diagnosis of PTSD is reflected in medical records from the Pasco County Sherriff's office dated in 2001-2002 as well as by the Veteran's brother, a medical doctor, who indicated that the PTSD was due to his MVA. However, since the Veteran's brother appeared to be a general practitioner, not a psychiatrist, the Board remanded this case for the Veteran to be afforded a psychiatric evaluation concerning the etiology of the PTSD. In the interim, VA medical records documented that the Veteran was being treated for PTSD. Eventually, after another Board remand, the requested examination was held in August 2011. The examiner opined that the Veteran did not meet the criteria for PTSD. The examiner indicated that the Veteran's account of the inservice sexual assaults was unreliable, stating that the account of the assaults had changed with regard to where the assaults had taken place and in the details of the account, which were very explicit on the examination. With regard to the MVA, the examiner noted that the VA medical records referred to PTSD being due to the MST and not the MVA. The examiner basically indicated that the Veteran was malingering and not reliable. As such, the examiner checked the PTSD criterion box for "no exposure to a traumatic event," as well as a lack of meeting the residual symptoms which would be associated with a traumatic event. Thereafter, additional VA medical records were received, which the Veteran's representative asserts were not of record previously, and which do in fact post-date the VA examination. These records document treatment for PTSD as well as associated psychiatric disorder, identified as a bipolar disorder, dysthymic disorder, chronic mood instability, depression, and anxiety. The treatment was provided and monitored by the Veteran's treating VA psychologist. This psychologist indicated that the psychiatric disability was due to the inservice MST. Full mental status examinations were performed in support of the diagnoses. The Veteran also attended group treatment sessions. The Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)); see also Wensch v. Principi, 15 Vet. App. 362, 368 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases for doing so). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). There is no "treating physician rule" requiring the Board to give additional evidentiary weight to this doctor's opinion. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993); and Chisem v. Brown, 4 Vet. App. 169 (1993). Although the Board may not ignore the opinions of treating physicians, the Board is free to discount the probative value of these physician's statements so long as the Board provides adequate reasons and bases for doing this. Sanden v. Derwinski, 2 Vet. App. 97, 100-01 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). In this case, though, there is no inherent reason for discounting the treating psychologist's opinion in favor of the VA compensation examiner's opinion, particularly since this private physician, being a psychologist, specializes in the diagnosis and treatment of psychiatric diagnoses, just as the VA compensation examiner. Thus, they both most certainly have the medical expertise required to comment. See Black v. Brown, 10 Vet. App. 279 (1997) (An opinion may be reduced in probative value, even where the statement comes from someone with medical training, if the medical issue requires special knowledge). The VA compensation examiner essentially did not believe the Veteran. However, his VA treating psychologist does believe the rendition that the Veteran presents regarding the inservice MST, which the VA psychologist has indicated resulted in the Veteran's psychiatric disability. There is virtually no possibility of absolute verification of the inservice MST. Thus, the matter rests on the credibility of the Veteran. While there are discrepancies in the MST attack, there are also consistencies regarding the type of sexual assault described by the Veteran. The VA treating psychologist has accepted that the Veteran's report of inservice trauma is sufficient to base a PTSD diagnosis on in this case. The Board is mindful that an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Instead, this need only be an as likely as not proposition, which in this particular instance it is for the reasons and bases discussed. Thus, the evidence in this case is so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulation. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. As such, there is probative evidence that the Veteran's PTSD, with associated psychiatric diagnoses. is etiologically related to inservice MST. The VA psychologist's diagnoses are considered credible and persuasive evidence which places the evidence for and against the claim in equipoise. Accordingly, the Board finds that the evidence in this case is so evenly balanced so as to allow application of the benefit-of-the-doubt rule and service connection for PTSD, with associated diagnoses to include a bipolar disorder, dysthymic disorder, chronic mood instability, depression, and anxiety, is warranted. A Cervical Spine Disorder The Veteran claims his cervical spine disorder is related to the 1984 inservice MVA. He maintains that he was involved in an accident while driving a military vehicle in New York and sustained injuries. Thus, he asserts that he sustained neck injury while in training status. Evidence from the Veteran's parents as well as a fellow servicemember (contained in his 201 file) indicated that the Veteran was in an automobile accident on May 24, 1984. However, no neck complaints were forthcoming until many years later. The first instance reflected in the STRs was dated in March 1991, when the Veteran reported that he was unable to move his neck. This occurred nearly seven years after the claimed 1984 accident. Thereafter, the STRs reflect that in February 1992, the Veteran was seen for tenderness of the paracervical muscle and the trapezius muscles. However, no specific injury was noted nor was disease diagnosed. More than 8 years later, a May 2000 letter from a private physician indicated that the Veteran had cervical degenerative disease. No etiology was provided. In April 2001, the Veteran was in a bus accident and was diagnosed with cervical strain. In June 2001, he also tripped and fell into a washing machine, and cervical strain was again noted. Records from the Pasco County Sherriff's office dated in 2001 indicated that the Veteran had cervical disability. Further, in September 2002, the Veteran was examined following a June 2001 car accident. The physician indicated that the Veteran had cervical radiculopathy with competent of myeloradiculopathy secondary to disc herniation and nerve root impingement. November 2002 private magnetic resonance imaging (MRI) revealed disc disease of the lumbar spine. It was noted that the back pain and radiculopathy began following an automobile accident. December 2002 MRI studies revealed disc disease. May 2003 records including x-rays revealed that the Veteran had disc disease of the cervical spine. In March 2004, the Veteran was involved in another motor vehicle accident. Private records reflected that after the accident, he had severe neck pain, among other symptoms. The pertinent diagnosis was chronic post-traumatic cervicalgia with associated cervical/brachial radiculitis. In April 2005, the Veteran was treated for chronic neck and back pain. He was diagnosed as having lumbar and cervical degenerative disc disease. The Veteran continued treatment for his cervical spine, thereafter. Due to the medical complexities in this case, the Board remanded the matter for the Veteran to be afforded a VA examination. In August 2011, the Veteran was afforded this examination which yielded diagnoses of chronic neck strain and degenerative disc disease of the cervical spine. The examiner opined that current diagnoses were not caused by or related to military service. The examiner reviewed the STRs, including the ones pertaining to neck complaints as well as service examinations which referred to no neck disease or injury or complaints thereof which post-dated the claimed 1984 accident. The examiner noted that the Veteran's contention that his neck problems commenced with the inservice 1984 car accident, reviewed the STR findings, and also considered the numerous post-service accidents. The examiner concluded that the current diagnoses began post-service and were unrelated thereto, citing to the aforementioned evidence. The Board recognizes the Veteran's competency to provide testimony as to certain lay and medical issues as he had training as a medic and can certainly make lay observations. However, with regard to his neck, the Board finds that he is not credible in his report of neck injury following the claimed 1984 MVA. The record does not reflect complaints in 1984. This is significant considering the voluminous amount of medical evidence contained in this case and the Board does not find it reasonable that the Veteran would not have reported neck complaints given his report of neck complaints following his numerous post-service accidents. Stated differently, the Veteran has a consistent history of making medical complaints and seeking treatment for a variety of medical problems. There is no record of the claimed 1984 accident. Assuming that the accident occurred, there is still no documentation of neck complaints for many years thereafter. Given the Veteran's history of reporting medical problems, the Board finds it inconsistent that he would not report neck complaints when he was purportedly experiencing them for years. The Board may consider whether the silence of the Veteran in reporting complaints regarding his neck when he reported other medical complaints constitutes negative evidence. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact). In this case, it does constitute negative evidence. Further, there is not just a lack of evidence; rather, there is evidence showing normal findings on inservice examinations. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); see also Dulin v. Mansfield, 250 Fed. Appx. 338, 2007 WL 2914797 (C.A. Fed. Oct. 5, 2007). In addition, the post-service evidence showed treatment and diagnosis of neck disabilities dated many years after the Veteran was last in the military. Also, he clearly was in several accidents causing neck injuries. Thus, even if a cervical disability was noted at any point previously, the record must show that current diagnoses are related to any injury during ADT or IDT, or disease noted on ADT, of which there is not any such notation. The Board therefore finds the opinion of the August 2011 VA examiner to be more probative than the Veteran's opinion. The VA examiner is both competent and credible in his assessment that current cervical spine diagnoses began post-service and independent of service. Accordingly, service connection is not warranted. A Nasal Disorder The Veteran testified before the Board is that he was injured in an MVA in the 1980's (the 1984 MVA) while driving a military truck in a convoy. He stated that he had injuries because he was not wearing a seatbelt. The Veteran indicated that he broke his nose during the accident. He claims that he has broken his nose repeatedly since then, including during other annual training, when his helmet slipped down and struck the bridge of his nose. The June 1992 separation examination revealed a history of multiple nasal bone fractures. Clinical records, including those dated in June 1992, confirm the history of fracture as well as a septal repair. March 2002 records of the Pasco County Sherriff's office noted that the Veteran was having problems with a bloody nose which had been bleeding for a week. A June 2008 computerized tomography (CT) of the sinuses revealed deviation of the septum to the right and some thickening. The Veteran was also evaluated and a notation was made that the Veteran had a history of a nose fracture from 20 years before. In October 2009, the Veteran sustained injury when a can fell from a cabinet onto his nose. A nasal obstruction was also noted that month. In April 2010, the Veteran was afforded a VA examination. The examiner, in reviewing the record noted a "June 3, 2008 ENT note and careful review of the records both document surg[ery] and trauma as a child prior to the service." The examiner ultimately concluded the Veteran's current nasal condition was unrelated to in-service trauma. However, a review of the June 2008 ENT notes revealed no evidence of a pre-service childhood nose trauma. Thus, the case was remanded for a new VA examination as this opinion was not probative due to the inaccurate history. See Kightly v. Brown, 6 Vet. App. 200 (1994). In August 2011, the Veteran was afforded a VA examination which yielded diagnoses of allergic rhinitis and status post nasal bone fracture. The examiner opined that current diagnoses were not caused by or related to military service. The examiner reviewed the STRs, including the ones pertaining to nasal fracture. However, the examiner concluded that the Veteran's nasal fractures had healed and there was no deviation. Although he had allergies (rhinitis), the examiner stated that the rhinitis did not have any known direct connection to his past nasal traumas and was less likely than not related to inservice nasal traumas. In sum, the Veteran clearly had nasal injuries during his service periods, but he currently does not suffer from any residual due to those injuries. The most recent examination confirmed that he does not have deviation or any other structural nasal problem. While he has rhinitis/allergies, the examiner indicated that they are unrelated to service. The Board recognizes that the Veteran has training as a medic and reports inservice nasal fracture. However, the fact that he sustained a nasal fracture been accepted as factually correct. The VA examiner examined the nose and definitively indicated that there are no current residuals of that fracture. In light of his examination and complete review of the record, the Board finds the VA examiner's assessment of no current disability to be the most probative opinion on that point. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). A "current disability" means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). There is no current residual of any inservice nasal injury. The fracture is healed. Thus, there is no disability in that regard. As noted, the VA examiner's opinion that the Veteran's rhinitis/allergies are not etiologically related to service is the most probative evidence on that point. Accordingly, entitlement to service connection is not warranted. A Headache Disorder The Veteran also claims that headaches began in the military. The Veteran complained of headaches in June 1981 and later contemporaneous with nasal trauma. In September 2002, the Veteran was examined following a June 2001 accident. The physician indicated that the Veteran had post-concussive syndrome with cephalgia and moderate cognitive deficits. In August 2011, the Veteran was afforded a VA examination. The examiner opined that the Veteran's recurrent headaches were less likely than not caused by his military service. The examiner noted that although the Veteran had a few complaints of headaches in service, they were connected to nasal trauma and later headaches to a car accident. The current headaches were stress/tension headaches in nature and also partially related to his current neck disorder. The Veteran, again, is competent to report that he has experienced headaches, including in service. The STRs reflect headache complaints, including in conjunction with an injury. However, the Board finds more probative the VA examiner's opinion regarding the Veteran's current types of headaches and their etiology. In other words, even if the Veteran had a headache related to an inservice trauma, his current headaches are not etiologically connected to that incident. The VA examiner provided rationale for his opinion regarding the nature of current headaches and addressed the post-service accident. Indeed, the records from that accident documented post-concussive syndrome with cephalgia. The Veteran did not provide such rationale. Thus, as the most probative evidence shows that current headaches are not etiologically related to service to include any inservice headache complaint, but are rather due to other causes, including post-service trauma, the Board finds that service connection is not warranted. Gastrointestinal Disability STRs dated in April 1992 showed treatment for acute gastroenteritis. Subsequent February 1993 records reported abdominal pain with a history of having a portion of the small intestine removed. Likewise, later private records from Bexar County Hospital District dated in January 1996 noted a history of abdominal surgery which apparently took place in the place 1980's. Likewise, an April 2001 record indicated that the surgery took place in 1989. In September 2003, the Veteran reported having abdominal pain and rectal bleeding. The next month, he was diagnosed as having GERD. In October 2003, the Veteran underwent an esophagogastroduodenoscopy and biopsy which revealed short segment of Barrett's esophagus, loose lower esophageal sphincter, and nonerosive gastritis. In November 2003, it was also noted that he had a short segment of Barrett's esophagus. An April 2005 private ultrasound of the right upper quadrant was negative. It was indicated that the Veteran had chronic cholecystitis. A May 2005 gastric emptying study yielded normal findings. A June 2005 CT of the abdomen was normal. In August 2011, the Veteran was afforded a VA examination which yielded diagnoses of GERD and Barrett's esophagus. The examiner opined that current diagnoses were not caused by or related to military service. The examiner indicated that the Veteran had surgery in the 1988-1989 time frame, undergoing a banded intestine for strangulated hernia. The examiner referenced the Veteran's subsequent inservice complaints and indicated that they were common gastrointestinal virus events or most likely residuals of the past surgery and there was no evidence of aggravation. The Board notes that there is no evidence that the Veteran suffered any gastrointestinal injury during a periods of ADT or IDT or disease or injury during a period of ADT. Rather, the most probative evidence of record, as supported by the record, establishes that the Veteran had "common gastrointestinal virus events" without last residuals. The Veteran underwent abdominal surgery during his general period of National Guard service, but the record does not reflect that this surgery was in any way related to an inservice injury, nor does the Veteran assert such. In order for disease to be service-connected, it must be incepted during a period of ADT. That is not the case here. In addition, although the Veteran had surgery prior to later ADT service, he is not entitled to VA's presumption of soundness for that later service. As noted, his "veteran" status and entitlement to VA presumptions was stabled for earlier service based on his entitlement to PTSD as being incurred due to that period. In any event, as indicated by the VA examiner, his current diagnoses are not related to service, even on an aggravation basis. The Board notes that the current diagnoses were made post-service by many years. The Board does not find that the Veteran's opinion that these post-service diagnoses are etiologically related to service to be as probative as the VA examiner's opinion that they are not etiologically related to service since the VA examiner made a detailed account of the Veteran's history, examined the Veteran, and provided rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). It is entirely within the Board's province to give more probative weight to certain pieces of evidence than others, so long as the Board provides adequate reasons and bases. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). Accordingly, service connection for a gastrointestinal disorder is not warranted. ORDER Service connection for PTSD, with associated diagnoses to include a bipolar disorder, dysthymic disorder, chronic mood instability, depression, and anxiety, is granted. Service connection for a cervical spine disorder is denied. Service connection for headaches is denied. Service connection for residuals of nasal fracture is denied. Service connection for a gastrointestinal disorder is denied. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs