Citation Nr: 1334431 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 11-22 446 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from October 31, 1974 to December 11, 1974. This matter initially came before the Board of Veterans' Appeals (hereinafter "Board") on appeal from a February 2009 rating decision of the Department of Veterans Affairs (hereinafter "VA" ) Regional Office (hereinafter "RO") in North Little Rock, Arkansas. In October 2011, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge (hereinafter "VLJ"). A copy of the transcript of that hearing is of record. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court of Appeals for Veterans Claims (hereinafter "Court") held that the scope of a claim should be construed based on the reasonable expectations of a non-expert, self-represented claimant, and the evidence developed during the claims process. In short, the essential requirements of any claim, whether formal or informal, are (1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). In the Veteran's case, the clinical record reflects diagnoses of various mental health disorders, such as depression, personality disorder not otherwise specified (hereinafter "NOS"), and bipolar disorder. However, in a statement received in April 2011, the Veteran specifically indicated that he did not have a posttraumatic stress disorder (hereinafter "PTSD") diagnosis. Hence, the Board has accordingly characterized the psychiatric disorder issue on appeal to encompass consideration of alternative psychiatric diagnoses, but to exclude PTSD. In June 2012 and March 2013 the Board remanded the claim to the RO via the Appeals Management Center (hereinafter "AMC") in Washington, DC for additional development of the record, to include obtaining outstanding treatment records, verifying the circumstances of the Veteran's honorable discharge in December 1974, scheduling a VA examination and medical opinion, obtaining clarifying medical opinion. The record shows substantial compliance with the June 2012 and March 2013 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). In July 2013, the RO issued a supplemental statement of the case (hereinafter "SSOC"), which continued to deny entitlement to service connection for bipolar disorder. This appeal was processed using the "Virtual VA" paperless claims processing system and the Veterans Benefits Management System (hereinafter "VBMS"). Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c) (2011). 38 U.S.C.A. § 7107 (a)(2) (West 2002). FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim for service connection for an acquired psychiatric disorder, to include bipolar disorder have been accomplished. 2. The currently demonstrated bipolar disorder is shown as likely as not to have had its onset during the Veteran's active service. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for bipolar disorder have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code (hereinafter "38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations (hereinafter "38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (hereinafter "the Federal Circuit") (as noted by citations to "Fed. Cir.") and the Court (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issues under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. A Veteran bears the "evidentiary burden' to establish all elements of a claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). The Board's duty is to first determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (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"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, 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. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (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 Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Duties to Notify and Assist The Board has considered the Veterans Claims Assistance Act of 2000 (hereinafter "VCAA") and its implementing regulations. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Given the favorable disposition of the claim for service connection, the Board finds that all notification and development actions needed to fairly adjudicate the claim have been accomplished. Under this circumstance, there is no prejudice to the Veteran in adjudicating the claim for service connection without further discussion of VA's duties to notify and assist. Bernard v. Brown, 4 Vet. App. 384 (1993). The Merits of the Claim Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). If chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 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 Veteran contends that he has a bipolar disorder that was incurred during active service, to include as due to stress in basic training. The Board finds after careful consideration that the evidence is at least in a state of relative equipoise on all material elements of the Veteran's claim for service connection for bipolar disorder, for the following reasons. (At the outset, it is noted that the following discussion addresses whether the Veteran's current psychiatric disorder is related to service. The Veteran entered service in sound condition, as will be discussed. Further, there is no clear and unmistakable evidence to rebut the presumption of soundness. Any evidence relating to a history of depression prior to service does not rise to the level of clear and unmistakable evidence of a preexisting disability. See VA examiner's opinion dated in May 2013.) The Veteran's service treatment records demonstrate a normal clinical psychiatric evaluation upon enlistment examination on October 31, 1974. Thus, it is presumed that he entered service in sound condition. In an associated report of medical history the Veteran denied having ever had depression or nervous trouble of any sort. A November 18, 1974, report noted he was placed on a 72 hour profile with no marching, running, or jumping. A November 29, 1974, treatment report noted he complained of left lateral leg area leg pain over the previous week. An examination was unremarkable. The treatment plan included arch supports. A December 11, 1974, statement signed by the Veteran indicates he underwent a separation medical examination more than three working days prior to his departure from the place of separation with no change in his medical condition; however, the available record does not include a copy of a separation examination report. A November 2008 service department report noted all available treatment records were submitted to VA. A September 2010 report noted a specific search for inpatient mental treatment records dated in 1974 at Fort Polk, Louisiana, revealed no records. The Veteran was provided notification of the unsuccessful VA effort in November 2010. Service personnel records include a December 1974 service personnel record addressing the Veteran's discharge from the U.S. Army, which indicates the Veteran was discharged before 180 active duty days due to his demonstrated lack of maturity and responsibility, which made him unsuitable for a soldier. This inability to adapt to the military life was deemed unsatisfactory. It was noted that the Veteran was counseled by his drill sergeants and superior officer, and had been sent to the "Confidence Builders Program." The Veteran was noted to have been sent to "CBP" but was still found to lack the demonstrated qualities in aptitude, attitude and motivation necessary for completion of basic training. It was noted he had been sent to a "CBP" but still lacked the demonstrated qualities in aptitude, attitude, and motivation necessary for completion of basic combat training. An associated statement signed by the Veteran declined a separation medical examination if the discharge was approved. A DD Form 214 shows he received an honorable discharge on December 11, 1974, for administrative purposes and that "Table 3-1, AR 601-210 applies." The Board notes that in correspondence dated in August 2011 the Veteran's service representative asserted that Table 3-1, AR 601-210 included psychiatric disorders as an issue on this table; however, no supporting evidence was provided for the record. The available medical evidence includes private treatment records from facilities such as "The Bridge Way" and "Baptist Health Occupational Health Clinic," which reflect inpatient psychiatric treatment in 2005, and that the Veteran had ongoing psychiatric treatment for bipolar disorder from February 2007. Also, the Board notes that VA treatment records dated in April 2008 show the Veteran complained of recurrent episodes of extreme agitation and that he reported he had numerous similar episodes since his teenage years often with alternating episodes of depression. A diagnosis of mood disorder was provided. A June 2008 report included a diagnosis of bipolar disorder, by history. Notably, Social Security Administration (hereinafter "SSA") records include medical records showing the Veteran reported a history of depression since age 12. In November 2009, "Dr. Milwee" the Veteran's VA clinical psychologist who has been treating him since September 2008, provided a medical opinion, in which it was noted that the Veteran had been diagnosed with Bipolar Disorder. Dr. Milwee observed that the symptoms of bipolar disorder, and the disorder itself could be triggered by exposure to significant distress. Dr. Milwee concluded that it was likely that the Veteran's bipolar disorder symptoms were exacerbated by his participation in military service. In May 2011 the Veteran underwent a VA psychiatric examination, during which the examiner observed that there were no service treatment records that indicated he received any type of psychiatric treatment while in the military. The examiner noted a letter dated in December 1974, with the subject "discharge from the United States Army," but found that the "reasons for proposed action" section was completely illegible. Consequently, the examiner found that it was impossible to determine exactly why he was discharged from the military. The Veteran reported that he had an incomplete memory for the events of that time, but that at one point he became severely depressed was placed in a room with a window and the people came and talked to him. He did not know whether he was in a hospital or whether he was in a different building, but he did recall that he was placed in a taxi cab and taken to the airport and flown home after he was discharged. He indicated that his parents picked him up at the airport, but did not know what was wrong with him and so ultimately told him to leave the house so that he would not have a negative impact on his younger siblings. He reported that he was basically homeless for the next several years before his depression lifted and he was able to begin work He had several failed marriages through the years and reports that his first psychiatric hospitalization was in 2005. The examiner observed the claims file records indicate hospitalizations at "Bridgeway" and at the VA in North Little Rock for bipolar disorder in June of 2008 and January of 2009. The Veteran was diagnosed with bipolar 1 disorder, most recent episode mixed, severe. The examiner observed that records were completely silent as to whether or not he received any sort of treatment for depression or manic depression while in the military, and was not able to determine the reason for his discharge without resorting to speculation. The May 2011 examiner's opinion was determined to be inadequate for VA rating purposes and another VA examination was ordered. "[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this regard, the Board notes that the May 2011 examiner's opinion was of a speculative nature. In Jones v. Shinseki, 23 Vet. App. 382 (2009), the Court held that a determination that a diagnosis or etiology opinion is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion. However, a bald statement that it would be speculative for the examiner to render an opinion as to etiology or diagnosis is fraught with ambiguity. For example, it is not clear whether the examiner lacks the expertise to render such an opinion, or whether some additional testing or information is needed, and possibly available, that would permit such an opinion, either of which would render the opinion inadequate for resolving the claim. Thus, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Cf. 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"). The Court in Jones further held that the examiner may also have an obligation to conduct research in the medical literature depending on the evidence in the record at the time of the examination. See Wallin v. West, 11 Vet. App. 509, 514 (1998). The phrase "without resort to speculation" should reflect the limitations of knowledge in the medical community at large and not those of a particular examiner. Id. The May 2011 VA examiner failed to explain why an etiology opinion could not be given without resorting to mere speculation. Thus, this evidence is of little to no probative value. In a statement received in June 2011, the Veteran reported that he was told he was most likely hospitalized in 1974 while in service, but that he could only recall being isolated in a room by himself while under a 24 hour watch for several days before being discharged. In a statement dated in July 2011, the Veteran's sister, a registered nurse, provided her observations of the Veteran's bipolar disorder symptoms. She noted that before leaving for boot camp the Veteran was active and involved in many hobbies, including raising animals and working outside on the house. He also worked in the cafeteria at school and worked odd jobs to make money as he got older. She noted that when the Veteran returned from service he appeared very tired, stayed in his room a lot and did not talk to his family very much. She opined that, with her medical training she identified the Veteran as having depression when he returned home from the Army. She also indicated that his diagnosis of bipolar disorder was appropriate. She noted that the Veteran exhibited no signs of bipolar disorder prior to joining the military, but that from the time of his discharge to the present, the Veteran had shown classic signs and symptoms of depression and mania befitting the bipolar diagnosis. She noted that he had suffered from many depressive and manic episodes over the years. In another statement dated in July 2011, the Veteran's brother described the Veteran's mental health condition before and after his military service. He recalled the Veteran was an active person who looked forward to his military service prior to joining, and noted that upon returning home he became very depressed. He noted that the Veteran was taken to see the family doctor to find out what was wrong with him, and that he was currently very depressed, unstable and unable to work. In a third statement dated in July 2011,the Veteran's mother-in-law who had known him since he was a child provided observation that prior to enlisting in the military the Veteran was a "vibrant young man full of promise" and that after his separation from service he was depressed and withdrawn. In a statement received in August 2011, the Veteran's spouse provided her observations of his behavior before, during and after his military service. In particular, she focused on his post-service symptoms, and described the Veteran as manic and severely depressed. In his VA Form 9, Appeal to the Board of Veterans' Appeals (hereinafter "Form 9") dated in August 2011, the Veteran argued that even though his service treatment records were silent for psychiatric treatment, he was depressed in service, which affected his performance and led to a total mental breakdown, and his eventual discharge from service. He indicated that his service treatment and personnel records showed that his performance deteriorated shortly after seeking treatment for foot problems on more than one occasion, due to painful bleeding blisters due to ill-fitting boots. He observed that when his performance suffered, he was placed in a "confidence building class," which he believed served only to intensify the stress and hopelessness he had been feeling. He indicated that these were the events that led to his depression and subsequent mental meltdown, and were the first manifestations of his bipolar disorder. He reported that after his total mental meltdown he was placed under a 24 hour watch and was eventually discharged and sent home. He observed that his discharge records showed findings that he lacked demonstrated aptitude, attitude and motivation, which he argued was a direct result of his depression. The Veteran noted that both private and VA treatment records indicate a history of depression and mental health issues with more than a 36 year history of treatment. He referenced a "The Bridge Way" admission note, dated in May 2005, which showed a "30+ year history." In another August 2011 statement, the Veteran again provided information as to his upbringing, pre-service mental state, his military experience, and his post-service mental state. He reported that prior to service he was a well-adjusted child and teenager who actively participated in many extracurricular activities, but that after suffering a mental breakdown in service following his confidence course, he became depressed, confused, and eventually aggressive. He noted that he was homeless soon after returning home from service because his family could not tolerate him, and that he had several near misses with the law. He reported that he struggled to hold a job, was estranged from his family, and had many episodes of mania, including one involving theft from a supermarket safe where he was working. In August 2011, Dr. Milwee provided a second medical opinion, in which he opined that certain elements from the Veteran's history that were reviewed suggest that symptoms of bipolar disorder first appeared during his time on active duty in the Army. Dr. Milwee opined that it was likely that the high stress/high demand environment of the Army contributed significantly to the development of his illness. Dr. Milwee believed that the records that were reviewed from the Veteran's time in the service detailed reasons for discharge that may well be explained by the presence of bipolar disorder. Dr. Milwee noted that there were no corresponding complaints in school records or from the Veteran's family members prior to his time in the military. During his October 2011 hearing testimony, the Veteran reported that when he first joined the military he did not experience any mental problems or physical problems. He indicated that he had excellent grades in school, had been participating in extracurricular activities, had two years of Reserve Officers' Training Corps (hereinafter "ROTC") training, and had been working bailing hay and tending to animal. He explained that his problems in service first began when he experienced physical discomfort because of blisters from his boots during basic training. He then began to have psychological problems when he began to feel incapable of dealing with his boot issues. He referenced an incident in service where he was cited for smoking in the chow line, and used it as an example of his mind not working properly. He described an experience in boot camp where people began to rag on him and pick on him because of his foot problems, which caused him a great deal of stress. He reported that he could not recall if he was treated for any type of mental health issue in service, but noted that he was taken somewhere for treatment, which he believed was a hospital. He indicated that he was watched 24 hours a day after experiencing a mental breakdown when he refused to get out of his bunk and do physical training. His spouse reported that the Veteran was forced out of his bunk on one occasion, and ended up on the ground in the fetal position because he could not cope with the stress. She noted that he was sent to the "confidence building" where his performance declined, which added more stress to him. The Veteran noted that once he was separated from service he began to seek treatment for mental health problems from a private practitioner within 10 days of discharge, but that he was unable to obtain records dated as far back as the early to mid-1970's. He reported that he was kicked out of his house after he returned home from service because his family could not cope with his problems. The Veteran's spouse noted that he began to undergo treatment at VA in approximately 2006, but that he had received treatment for the previous 37 years for his psychiatric disability, although he was not diagnosed with a specific disorder for a number of years. The Veteran noted that Dr. Milwee provided an opinion that the Veteran's stress during service triggered an onset of bipolar disorder. He noted that he was in receipt of SSA benefits for his bipolar disorder since 2007. In June 2012, the Veteran provided a statement clarifying SSA records that reflected reports that he had experienced depression since he was 12 years old and that his grades declined in the tenth grade. He noted that during the tenth grade he had studied French, was a member of the ROTC rifle team, and had raised a bull and two sheep, all while being employed at a supermarket and being active with his church. He explained that his grades suffered due to his French class, and because he was overextended by his extracurricular activities. He also denied experiencing depression at 12 years old, and cited to the reports of his friends and family who provided written testimony that he was a happy, normal, well-adjusted child. He indicated that he began to seek treatment for his depression from "Dr. Curry," his family doctor, in 1975. He noted that he could no longer obtain any treatment records from Dr. Curry because Dr. Curry was deceased. He also noted that in late 1975 he was treated at the Permian Basin MHMR clinic, wherein he was diagnosed with depression and was prescribed an antidepressant. He reported that it was too costly for him to fill the prescription. He indicated that he had made an attempt to obtain treatment records from this facility, and was awaiting response. He also acknowledged that he had trouble with the law and was jailed overnight, due to charges of theft. In June 2012, the Veteran underwent a second VA mental disorders examination, and was again diagnosed with bipolar disorder NOS. The examiner noted that the Veteran had a post-service social history of being married for 12 years to his fifth wife. The Veteran reported that he had lived with both parents growing up, and that he raised rabbits, chickens, cows, goats and sheep. He noted that he had one brother and one sister, and was close to his brother and had some contact with his sister. The Veteran reported that the longest job he held was working for 12 years for the oil company from 1980 to 1992. The examiner noted that the Veteran did not have any legal and behavioral history, and that he denied drug and alcohol use, although he did use cannabis 2 years previously to the examination. The Veteran reported that he was in ROTC in ninth and tenth grades, and joined the service at the age of 17 after taking the General Educational Development (hereinafter "GED") test. He noted that everything was fine when he enlisted in the service, but that at around day 30, his shoes did not fit properly and his feet began to hurt after marches. He noted that a sergeant began to yell at him when he fell back during a march because of his feet. He also reported an incident where he was smoking in a chow line, and was made to smoke and do push-ups by a drill sergeant until he went through the pack. He indicated that this experience made him get sick, drop his food, and be placed on "KP duty." He described being sent to the confidence course, which he reported made him feel worse because he felt like it was impossible to finish. He claimed that he shut down, and lay in bed until he was removed from service and sent home. He reported that when he arrived home he was in the same depressed state as he had been while in service. He indicated that he was homeless for 1 and a half years immediately following service because of his psychiatric disorder. The examiner observed that the Veteran's service treatment records were completely silent as to any mental health complaints or treatment, and separation examination noted no change in the Veteran's health condition. Moreover, entrance examination did not reflect any mental health problems. The examiner concluded that based on this information, it was less likely as not that the Veteran's bipolar disorder had its origins in active military service. In July 2012 the Veteran underwent a VA medical opinion to address the conflicting medical evidence of record, wherein he was again diagnosed with bipolar disorder. The examiner noted that there were no changes from the June 2012 examination report. The examiner noted that the service treatment records were silent with regard to complaint or treatment of mental health/bipolar disorder symptoms, thus it continued to be the opinion of the examiner that the Veteran's currently diagnosed bipolar disorder less likely as not had its origins during the Veteran's 2 months in the military. In December 2012, a VA examination addendum was provided, wherein it was acknowledged that a review of the Veteran's December 1974 Army discharge papers revealed that the illegible component indicated that the Veteran was discharged due to "lack of maturity and responsibility inability to adapt to military life." The examiner opined that these are not symptoms associated with bipolar disorder, and concluded that the previous opinion that the current bipolar disorder was less likely as not related to military should remain unaltered. In May 2013, another VA medical opinion was provided, in which the examiner indicated that a review of the conflicting medical evidence had taken place. The examiner opined that while some documents stated that the Veteran reported depression and agitation during childhood/adolescence, there was not sufficient evidence to meet criteria for clear and unmistakable evidence that the bipolar disorder existed prior to service, as the enlistment exam noted no complaints. The Board finds that the June 2012 VA examination report and numerous addenda are inadequate insofar as they do not account for the Veteran's and his family's lay statements that indicate he did not have symptoms of any psychiatric disorder while in service, but that he did have symptoms of a psychiatric disorder immediately following his separation from service. The Board notes that an examiner cannot ignore lay evidence of an in-service injury and base an opinion that there was no relationship to service solely on the lack of in-service corroborating medical records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also 38 C.F.R. § 4.2 (2013) (stating that if the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes an examination, even if not required to do so, an adequate one must be produced). Most recently in September 2013, "Dr. Miller" of the "Fowler Institute" provided a medical opinion. Dr. Miller indicated that the Veteran's entire claims file and medical history files, including his service personnel and treatment records, dated from October 1974 to December 1974, were reviewed. Dr. Miller also noted that lay statements, pre-service educational records, post-service private treatment records from "The Bridgeway" and "Baptist Hospital," and VA treatment records, along with VA examination reports were reviewed. Dr. Miller noted that while reviewing the Veteran's claims file detailing his time in service, she became aware that certain elements from the Veteran's history were missing or contradicting, which made it difficult to determine his mental health at the time of his discharge. Dr. Miller noted that in October 1974, the Veteran's psychiatric examination was normal; that service discharge records, dated in December 1974, were confusing as to why and how the Veteran was separated from service; and that treatment records from that time period could not be located for that time period. Dr. Miller opined that, according to the statements in support of claim, past school records, the Veteran's personal statement and history, which were noted in numerous treatment records as well as during the clinical interview before the record review was completed, that there were no corresponding complaints about the Veteran's mental illness prior to his enlistment in the Army in October 1974. Dr. Miller observed that the record also established that the Veteran had issues with the law, interpersonal relationships, job stability and severe mental illness, which caused numerous hospitalization, after he was discharged from the service. Dr. Miller indicated that the documentation reviewed also showed that the Veteran consistently reported to numerous mental health professionals the negative impact that the high stress/high demand environment of the Army had on his mental health, especially during his time attending the confidence building classes and when he was punished by a drill instructor and suffered from severe foot pain. Dr. Miller concluded that the Veteran's bipolar disorder was more likely than not (greater than 50 percent chance) due to his time in service. Dr. Miller explained that bipolar disorder was often triggered or exacerbated by significant environmental stressors, so the environment that was described by the Veteran during his time in active duty likely triggered his bipolar disorder. Dr. Miller noted that the Veteran's recollection and individual documentation of the change in the Veteran's mental health after being separated from the service appeared to be detrimental to his ability to succeed professionally and personally. Dr. Miller observed that before he enlisted in the service, the Veteran appeared to be a relatively healthy, happy, stable teenage boy, which was documented by the staff physician on the Veteran's first day of active service. However, Dr. Miller observed that according to the documentation reviewed, the Veteran was discharged and sent back home to his family in a very different emotional state than he was when he enlisted. The Board finds the medical opinion of Dr. Miller, supported by the medical opinions of Dr. Milwee, to be the most persuasive evidence of record insofar as Dr. Miller's opinion was informed by a thorough review and analysis of the entire record. Further, it reflects a clear and unequivocal opinion related the Veteran's bipolar disorder to his military service. Moreover, Dr. Miller explained that, according to the statements in support of claim, past school records, the Veteran's personal statement and history, which were noted in numerous treatment records as well as during the clinical interview before the record review was completed, that there were no corresponding complaints about the Veteran's mental illness prior to his enlistment in the Army in October 1974. Dr. Miller observed that the record also established that the Veteran had issues with the law, interpersonal relationships, job stability and severe mental illness, which caused numerous hospitalization, after he was discharged from the service. This reasoning adequately shows that Dr. Miller's conclusions were supported by the relevant and material information. In short, Dr. Miller's opinion is factually accurate, fully articulated, and based on sound reasoning. Thus, it carries significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet.App. 295 (2008). Moreover, the Board observes that the Veteran, his friends and his family have attested to his long-term treatment for bipolar disorder since military service, which, as lay people, they are competent to report. Jandreau v. Nicholson, 492 F.3d 1372 (2007) (lay evidence can be competent to establish diagnosis of a condition when a layperson is competent to identify the medical condition, or reporting a contemporaneous medical diagnosis, or the lay testimony describing symptoms supports a later diagnosis by a medical professional). They are also competent to report that he did not experience symptoms of depression prior to his enlistment in service. Further, the Board considers the Veteran's, his friends and his family's assertions of a continuity of psychiatric symptomatology since service to be credible in the absence of any evidence expressly negating those assertions. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (finding that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). As noted above, when, after consideration of all evidence and material of record in a case, there is an approximate balance of positive and negative evidence regarding any material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail."). There is evidence of that the Veteran was counseled in service after he demonstrated lack of maturity and responsibility, which made him unsuitable for a soldier, for which he was enrolled in the confidence builders program, along with subsequent medical findings of bipolar disorder thereafter and competent and credible lay testimony that the bipolar disorder did not precede service, as well as credible supporting evidence of a chronic bipolar disorder since service and a positive nexus opinion linking the Veteran's current bipolar disorder to stress he endured in service. Based on the foregoing, there is at least an approximate balance of positive and negative evidence regarding the issue at hand, and the Board finds that the evidence raises at least a reasonable doubt as to whether the Veteran's current bipolar disorder is etiologically related to his military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303. The Board also observes that the Court has cautioned against seeking an additional medical opinion where favorable evidence in the record is unrefuted. The Court specifically indicated that it would not be permissible to undertake further development if the purpose was to obtain evidence against an appellant's claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Thus, for the reasons described above, the Board concludes that there is a reasonable doubt as to whether the Veteran's current bipolar disorder is etiologically related to his military service. To the extent that there is any reasonable doubt, that doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board concludes that service connection for bipolar disorder is warranted. ORDER Service connection for bipolar disorder is granted. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs