Citation Nr: 1512079 Decision Date: 03/20/15 Archive Date: 04/01/15 DOCKET NO. 07-10 636 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUE Entitlement to service connection for an acquired psychiatric disability. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from January 1996 to January 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating of the Department of Veterans Affairs (VA) Regional Office (RO) Cheyenne, Wyoming. In October 2007, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims file. This case was remanded for additional development in October 2008, January 2010, October 2011, and October 2012. The case has since returned to the Board for the purpose of appellate disposition. As will be discussed, the Agency of Original Jurisdiction (AOJ) is deemed to have complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a July 2013 decision, the Board denied the Veteran's claim for service connection for an acquired psychiatric disability. The Veteran appealed the Board's decision to the Court. While the matter was pending before the Court, in June 2013, the Veteran's attorney and a representative of VA's Office of General Counsel filed a Joint Motion for Remand. In an August 2014 Order, the Court vacated the Board's October 2012 decision and remanded the matter for readjudication in light of the Joint Motion. In October 2014, the Veteran submitted a VA Form 21-22a, Appointment of Individual as Claimant's Representative, in favor of Robert V. Chisholm. In November 2014, the Board issued a decision denying the claim for service connection for an acquired psychiatric disorder. However, this decision was subsequently vacated in November 2014 due to a denial in due process of the law, to allow the Veteran's newly appointment attorney time to submit additional evidence. In December 2014, the Veteran's attorney submitted additional written statements and evidence including a December 2014 social worker report and December 2014 psychological evaluation, along with a waiver of original RO consideration of the evidence. This evidence is accepted for inclusion in the appeal. A review of the Veteran's Virtual VA and VBMS electronic claims file reveals additional VA treatment records dated through November 2012, which have been reviewed by the RO and the Board in conjunction with the current appeal. FINDINGS OF FACT 1. Clear and unmistakable evidence reflects both that that the Veteran had depressive disorder prior to service and that this disability was not permanently aggravated during in service. 2. Anxiety disorder and panic disorder with claustrophobia/agoraphobia were not manifested in service and are unrelated to service. 3. A personality disorder has been identified. CONCLUSIONS OF LAW 1. A depressive disorder clearly and unmistakably preexisted service and was not aggravated thereby; the presumption of soundness at entry is rebutted with respect to this disease. 38 U.S.C.A. §§ 1110, 1111, 1153, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2014). 2. Anxiety disorder and panic disorder with claustrophobia/agoraphobia, or other acquired psychiatric disorder were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 3. A personality disorder is not a disease or injury within the meaning of the law providing compensation benefits. 38 C.F.R. § 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014)) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In an October 2005 pre-rating letter, the RO notified the Veteran of the evidence needed to substantiate this claim. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). While Dingess notice was not provided until March 2006, after the initial adjudication of the Veteran's claim, it was thereafter readjudicated on a number of occasions, most recently in February 2013. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records and all of the existing, identified post-service private and VA treatment records. In November and December 2011, VA opinions were provided with regard to the claim at issue herein as to an acquired psychiatric disorder. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board has considered the Veteran's contentions that these opinions were not adequate because he was not actually examined by the opinion provider. However, an examination was not necessary in this instance, because there is extensive evidence of record as to the current diagnoses assigned to the Veteran's acquired psychiatric disorder. For the reasons discussed below, the VA opinion reports, in particular the first November 2011 report, is found to be adequate. During the October 2007 Board hearing, the undersigned informed the appellant that it was incumbent upon him to submit any potentially relevant evidence in his possession in support of his claim. The undersigned questioned the Veteran in such a way as to solicit any potentially relevant evidence that had not already been submitted or obtained. This action provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, supplemented VA's compliance with the VCAA, and complied with 38 C.F.R. § 3.103 (2014). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claim on appeal is thus ready to be considered on the merits. II. Analysis As an initial matter, the Board notes that the Veteran does not allege, and the evidence does not reflect, that the disability for which he claims entitlement to service connection is the result of participation in combat with the enemy. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2014) are not applicable. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. However, 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 38 U.S.C.A. § 1101. With respect to the current appeal, this list includes psychoses. See 38 C.F.R. § 3.309(a). However, since-as discussed below in greater detail-the Veteran has not been diagnosed as having a psychosis, consideration of continuity of symptomatology under the provisions of 38 C.F.R. § 3.303(b) is not warranted. A November 1995 report of medical history documents that the Veteran reported a history of depression or excessive worry and indicated that he had been previously treated for depression related to family problems and had also been hospitalized for depression. He stated that he had been hospitalized for two days only and underwent ten sessions of psychoanalysis. No follow-up had been recommended. A November 1995 report of medical examination shows that no notation was made with regard to psychiatric examination (while all other body systems were noted to be normal or abnormal), and a notation was noted as to a referral. A subsequent notation shows that a psychiatric consult from Fitzsimons was reviewed, and there was no psychiatric disorder on evaluation from a psychiatric social worker. The evaluation had been done secondary to a previous history of counseling. A diagnosis of clinical depression was noted and then crossed out. A June 1997 service record shows that the Veteran complained of emotional problems and stress associated with inspection the previous night. He denied suicidal or homicidal ideation but stated that he blacked out for a few minutes and had a history of depression. On objective evaluation, the Veteran was clean and well-spoken. He maintained fair eye contact. At times, he was stressed and agitated. He denied delusions and hallucinations. The assessment was adjustment disorder and possible depression or stress. He was to follow up with a consult. A July 1997 service record shows that the Veteran underwent mental health evaluation. He was referred for an evaluation as to fitness for duty as a result of a violent reaction to stress, which led to vague suicidal ideation. The Veteran reported difficulties with service starting after boot camp. He had recurrent thoughts of harming other people and reported that he may act on those thoughts to harm others if he is retained. He reacted with uncontrolled anger when he was ordered to have his room inspection ready by a certain time. He described similar episodes in the past, in which he had difficulties controlling his anger and broke his hand punching a locker. He described a longstanding history of neither desiring nor enjoying close relationships with other than first degree relatives. He almost always chose solitary activities, took pleasure in few, if any activities, appeared indifferent to praise or criticism of others, and showed emotional coldness, detachment, or flattened affectivity. He reported being hospitalized at age 17 for depression and placed on Prozac for almost one year. He continued psychiatric counseling until he was 21, when he enlisted. He received a waiver upon his enlistment and was reevaluated in October and November of 1995, in which no clinical indicators of depressions were found, and he was permitted to enlist. Following examination, the diagnoses were adjustment disorder with depressed mood and schizoid personality disorder. The Veteran was not considered to be mentally ill but manifested a long-standing disorder of character and behavior which was of such severity as to render him unsuitable for continued service. Further counseling was not recommended as this would not change his future maladaptive behavior and would only increase the likelihood of the Veteran to act out. He was deemed fit to return to duty for immediate processing for administrative separation. An August 1998 service record reflected that the Veteran reported for an appointment one year since his last. He still had periods of feeling down and unhappy but they were less frequent. He continued to remain isolated and tended to stay to himself. At times, he reported that he was motivated to complete his active duty service. His frustrations and thoughts of harming others had ceased. Following evaluation, the diagnoses were depressive disorder, by history, in partial remission and schizoid personality disorder. The Veteran denied any suicidal or homicidal ideation, intent, or plan. There were no psychological contraindications for him to work within his rate and be on full duty status. His prior history of depression had improved and was not currently a problem. In December 1999, the Veteran's separation psychiatric examination was normal. On a report of medical history completed at that time, he reported a history of depression or excessive worry. Private treatment records dated from May to November 2005 indicate that the Veteran was assessed with panic disorder with agoraphobia. An August 2005 private emergency room record shows that the Veteran reported difficulties with anxiety and headaches. He had to drop out of an occupational therapy program the previous spring due to social anxiety and panic attacks. He saw a psychiatrist last June but had been unable to tolerate medication due to side effects. The Veteran denied any difficulties with anxiety until last spring with the exception of some heightened anxiety when he was deployed in 2002. He was not officially treated for generalized anxiety disorder until last June. Following examination, the assessment was spells with suspected anxiety disorder with history of an inability to tolerate prescribed medications for anxiety. An August 2005 private treatment record shows that the Veteran could trace anxiety symptoms back to at least junior high. He then stated that the symptoms got better while he was in service. After 9/11, the anxiety and panic persisted for about six months and then improved. Last fall, he noticed a recurrence of symptoms. Following examination, the diagnoses were social anxiety disorder and anxiety disorder, not otherwise specified. An October 2005 private record indicates that the Veteran was referred for evaluation and treatment of anxiety symptoms. He reported experiencing his first full-blown panic attack while attending a class one year ago. They subsequently became so severe that he dropped out of school. While he described himself as shy, the Veteran stated that he did not have panic attacks until one year ago. Also within the past year, the Veteran reported he begun to experience intrusive thoughts related to obsessive-compulsive disorder. His problem with claustrophobia also arose within the past year. He also described clinically significant symptoms of depression since his anxiety became severe in the spring of 2005. When describing his service, the Veteran indicated that he was performing extremely well until he got into a fight, badly beat another soldier, and was required to attend psychological evaluations and therapy for a year because others felt that he did not show enough remorse. The experience was highly stressful. Despite this difficult year, the Veteran continued to excel in the Marines and finished his four-year tour with the unusually high rank of sergeant. However, he was denied security clearance due to his psychiatric history. Following examination, the examiner diagnosed social phobia generalized type, obsessive-compulsive disorder, specific phobia situational type (claustrophobia), and major depressive disorder. A November 2005 private treatment record showed that the Veteran was referred because he felt anxious all the time and had anxiety attacks. Among the sources of the Veteran's anxiety were his experiences on ship while in the Marines. He described the quarters are extremely confining and causing him to be claustrophobic. This was reinforced by his inability to sit in a classroom without a panic attack. His treatment over the past several months was noted. The diagnoses were generalized anxiety disorder, panic disorder with agoraphobia, dysthymic disorder, obsessive compulsive disorder, and personality disorder not otherwise specified. In a December 2005 written statement, the Veteran indicated that his initial anxiety and social problems began during service. In 1997, he got in a fight with a fellow soldier and was under evaluation for the next year. Because he was treated differently from the other Marines, his anxiety level compounded greatly during that year. In a February 2006 written statement, the Veteran's private psychiatrist indicated that the Veteran's most consistent diagnosis was severe panic disorder with agoraphobia. He also experienced intermittent depressive symptomatology for many years and dating back prior to his time in the Marines. While the possibility of bipolar disorder was considered, it was ruled out. As his history developed, it became apparent that his struggle with panic disorder dated to his time in the Marines. He described worsening panic attacks, anticipatory anxiety, and phobic avoidance that began to impair his ability to function. In a May 2007 written statement, the Veteran's private psychiatrist indicated that his most compatible diagnosis was severe panic disorder with agoraphobia, along with dysthymic disorder (chronic depression). As his history was developed, it became apparent that his struggle with panic attacks, anticipatory anxiety, and phobic avoidance dated back to his time in the Marines. He described symptoms at that time that impaired his ability to function. VA outpatient records dated from May to October 2007 show ongoing treatment for major depression disorder, panic disorder, agoraphobia, generalized anxiety disorder, and obsessive compulsive disorder. In October 2007, the Veteran testified before the undersigned. His representative contended that there was not sufficient evidence to rebut the presumption of soundness that the Veteran was entitled to at entrance into service. The Veteran indicated that his hospitalization in 1991 was for depression. It was a hormonal imbalance due to puberty and lasted no longer than six months, after which he stopped medication. The Veteran's representative asserted that the Veteran's private psychiatrist had reviewed his service records. In August 2009, the Veteran underwent VA examination. His claims file was not reviewed. The Veteran's medical records were reviewed, and the examiner opined that the Veteran was a reliable historian. The Veteran described an incident when another service member put his genitals near the Veteran's face while he was sleeping and took photographs. The Veteran now believed this was a prank but was angry at the time. He also described getting in a physical altercation with a superior in 1997. He was psychiatrically evaluated and recommended for separation. Instead, he underwent psychiatric evaluation for one year and was restricted from certain kinds of duty. After service, the Veteran attended college and obtained an associate's degree in 2004. He began working in September 2004, while continuing his education but dropped out in March 2005 because of his anxiety. He thereafter worked until August 2005. Subsequently in August, the claims folder was made available for review, and the examiner evaluated the Veteran again with this additional information. The Veteran reported getting treatment during service from August 1997 to August 1998. He denied ever having been an inpatient or outpatient. The Veteran succeeded in the Marines following his psychiatric evaluation, receiving awards. The Veteran reported that his performance was excellent and his was promoted to his satisfaction. He also received honors. The Veteran reported his first inpatient treatment at age 17 for acting out at school. He was in the hospital for two months, and then attended as an outpatient. Soon thereafter, the Veteran stopped medication and counseling. While the Veteran reported anxiety during his Marine service, he performed excellently. Thereafter, the Veteran was taking classes in 2005 for occupational therapy and started feeling anxiety, shakiness, numbness in his extremities, and sweaty. His first attack was in a classroom with forty students, which was overcrowded. He initially had improvement from medication and treatment but then regressed in 2006. Since 2006, the Veteran received treatment from VA. Following examination, the diagnoses were social phobia with anxiety, bipolar disorder type II, and avoidant personality disorder. The examiner noted that the Veteran's symptoms associated with chronic depression or bipolar disorder began at age 17, which was when it usually started. With regard to whether this condition got worse during service, the examiner stated that it was hard to say, since the incident sounded more like an interpersonal issue and an inability to accept an authority figure, and ongoing psychiatric treatment was not deemed appropriate. In a November 2009 written statement, the head of psychology of the Veteran's college indicated that he remembered speaking with him on several occasions during the 2002-2003 academic year about difficulties with anxiety and depression that he experienced as a result of service. In a December 2009 written statement, the Veteran's parents indicated that the Veteran attended group sessions in 2000, which were provided by his college. He continued with them until 2005, when he sought other help. In March 2010, the examiner that conducted the August 2009 VA examination reviewed the claims file and indicated that the diagnoses were social anxiety disorder and avoidant personality disorder. She appears to have reconsidered her previous diagnosis of bipolar disorder. The social anxiety disorder had been causing impairment in his life since he was a teenager. The symptoms and treatment given to the Veteran as a teenager were a clear indication of a psychological problem, since the treatment continued until age 21. During service, the Veteran continued to have problems with anxiety and phobias such as claustrophobia. This continued until the Veteran became violent and was not remorseful. Therefore, he was given a diagnosis of antisocial personality disorder. After separation, the Veteran was doing average in life until he was in a social setting and became anxious in 2005. He also has agoraphobia and claustrophobia that are a part of the social phobia. Social anxiety disorder has been the most important psychodynamic in the Veteran's life. He admitted that his father ridiculed and belittled him starting in early childhood. Also, the death of his brother at age 13 played a significant role in heightened anxiety. As a result of social phobia, the Veteran developed avoidance as a defense mechanism. The physician did not see service as any contribution to the Veteran's disorder. This problem started in childhood and was worse at age 17. Counseling continued until age 21. His condition was known during service and an ongoing problem, leading to his administrative separation. The disorder was a lifelong ongoing problem and did not respond to medication. She indicated that getting records from the facility that hospitalized the Veteran at age 17 would be helpful. In a June 2011 written statement, a private facility confirmed that the Veteran had been hospitalized there in 1991. The records had been kept for ten years and had now been shredded. In November and December 2011, the Veteran's claims file was submitted to three psychologist or psychiatrists for review. In the first November 2011 report, the VA psychiatrist opined that the claimed condition, which clearly and unmistakably existed prior to service was not aggravated beyond its natural progression by an in-service injury, event, or illness. The psychiatrist explained that the Veteran had a history of depression that existed prior to years of service in the Marines, which was waived by the Marines prior to acceptance into service. The Veteran had been hospitalized at age 17 for depression and treated until age 21. He was treated in service by a psychologist from 1997 to 1998 for adjustment disorder with depressed mood and schizoid personality disorder after a physical altercation with a superior officer. At the end of this therapy, the Veteran informed his treating psychologist that his periods of not feeling happy were less frequent than prior to therapy. Ongoing psychotherapy was not deemed needed. The Veteran was not hospitalized for depression during his time in service. The final diagnosis following therapy was depressive disorder, by history, in partial remission. The absence of hospitalizations and the Veteran's good response to treatment demonstrated that his pre-existing depression was not caused by his experiences in service or worsened by his experiences in service. With regard to the various anxiety disorder diagnoses, there was no evidence that they existed prior to or during service. The Veteran first complained of anxiety when taking classes in 2005. His problems with social anxiety, panic attacks, and claustrophobia began in 2006. He was also diagnosed as having social phobia in 2010. There was no indication in the service records of an anxiety disorder of any kind. While a 2007 written statement from a private psychiatrist indicated that anxiety symptoms began during service, there was no evidence from the service records to support that statement. The anxiety disorders cannot be said to have originated in or to have been worsened by, service. There was no evidence that the Veteran had an anxiety disorder of any kind while in service. Likewise, there was no evidence of bipolar disorder during service. The second November 2011 VA report shows that a psychiatrist opined that the Veteran's claimed disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In addition, he opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The rationale was that the Veteran was an inpatient at age 17 for acting out behavior. He had authority problems and was prescribed medication for depression. He was in service from 1996 to 2000. He had an altercation with a peer and another altercation with a superior. The Veteran showed no remorse and had difficulty with his superior in the working section. His problem with authority figures was pre-existing and not aggravated by service. In the December 2011 VA record, a psychiatrist provided an opinion that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness and that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The rationale was that the identified condition, which existed prior to service, was addressed on his entry examination in November 1995 as well as in July 1997. There were no injuries, events, or illnesses which occurred while in service noted in the claims file that would have contributed to or aggravated the identified psychiatric illness. The Veteran's exit physical conducted in December 1999 revealed no psychiatric difficulties at that time. The psychiatrist further indicated that the current level of severity of the Veteran's disability was greater than the baseline prior to service but was not aggravated beyond the natural progression of the disease. The rationale was that the Veteran's difficulties were identified in 2005 during evaluations completed that year. The indicated the onset of symptoms in the past year. His identified symptoms existed prior to service, the Veteran received treatment prior to service and waivered into the Marines. He also appeared to have been discharged secondary to an inability to adapt, which was an indication of a psychiatric condition that existed prior to service. The Veteran clearly and unmistakably had depression that pre-existed service. There was clear and unmistakable evidence that the disorder was not aggravated by service. In a March 2013 written statement, the Veteran's VA social worker indicated that he had treated the Veteran for many years. He presented initially with medical concerns of developing multiple sclerosis but had been subsequently afflicted with depression and anxiety, secondary to neurological changes. Multiple sclerosis was ruled out after evaluation but neurological changes were identified in the brain. The Veteran had been hospitalized once during his tenure with this provider, which was unproductive. He had been maintained on outpatient treatment since that time. No service records were review by the social worker. However, the Veteran had been subject to military sexual trauma during service. He noted that, in males he had treated over the years, such events cause a psychological imprint that pervades the sense of self and identity across the lifespan. This, in fact, may be just such a case. In addition, the Veteran may have been exposed to chemical neurotoxins during service, which would account for the paradoxical effects witnessed when he had been prescribed psychiatric medications. The VA social worker had witnessed such events from veterans in the past who had been verifiably exposed to such toxins. He found the Veteran to be credible, honest, and existing with no semblance of fabrication. He remained afflicted with major depression disorder, panic disorder, and generalized anxiety disorder exacerbated, if not existent, from his service. He attested to these opinions following over 15 years of practice in the VA healthcare system and a total of 20 years of professional practice. In a written statement dated in December 2014, the Veteran's VA social worker indicated that he stood by his records and previous letters, case summaries, and treatment notes. He noted that the Veteran had a diagnosis of major depressive disorder, generalized anxiety disorder, and panic disorder, which he determined were less likely than not related to service. He noted that the Veteran completed basic training, combat training, and deployed. He underwent severe sexual hazing following a prolonged military exercise in which he was made to remain without sleep for an extended period of time. The pictures of the hazing incident were posed in a public area. He noted that the severe stress culminated in the Veteran's assault on another Marine when he was provoked, and subsequent military arrangements served to continue provision of stress and humiliation. The social worker indicated the harm in service continued to be displayed in the Veteran's emotional core, behavioral ability, and cognitive functioning, despite his best efforts in seeking resolution. When his actions failed to produce meaningful results, the Veteran sought out treatment. The social worker found the Veteran's report of the in-service sexual trauma to be credible. In so finding, the social worker noted that he observed the Veteran's behavior during treatment sessions, as well as the Veteran's family members during family sessions, which lent credibility to the Veteran. He noted that the Veteran's history and symptom presence had not wavered in years of treatment, which stood in contrast to many other veterans he had treated in 17 years. He opined that, based on clinical work with the Veteran over several years, there was a clear acceptance that his adverse military experiences of such a personal nature contributed immensely to the exacerbation of any depressive qualities and certainly propagated anxiety and panic events. In a December 2014 report, private psychologist Dr. L. noted that he interviewed the Veteran for over hours and his records were reviewed. He noted that while the Veteran was hospitalized in 1991 for depression, he was not diagnosed with a psychiatric disorder at service entrance was found qualified for service. The Veteran again discussed the sexual assaulting/hazing incident and noted that after the incident, he was never treated the same by his peers or those in authority. He was mocked and taunted, which eventually led to a physical altercation. He reported that in the last part of his enlistment, his anxiety and depression had grown as a result of the emotion abuse and he was suffering from "full-blown panic attacks" and severe social phobia by the end of his service. He indicated that it was only when he felt secure in a protective therapeutic relationship with his current therapist that he felt safe to reveal the sexual assault. The Veteran expressed that he made a complete recovery from the 1991 hospitalization by the time of his enlistment in 1996, with no interference on his work or social functioning. However, after service he had not been able to hold an unprotected employment position for more than a year due to anxiety, panic attacks, and discomfort in interacting with others. Dr. L. discussed the Veteran's post-service employment history, and noted that, when compared with his pre-service employment history of working full-time with no anxiety or difficulty in maintaining the requirements of a full-time position, it was clear that he had been disabled from working. He found that the Veteran met the criteria for diagnoses of social phobia, generalized type, major depressive disorder, and that the diagnoses are related to his service. He noted that there was no evidence of him having social phobia prior to service, but while there was evidence of depression prior to service, he went on the graduate high school, live independently, find and maintain employment, and be accepted into service with no psychiatric disorder found at entrance. The examiner further opined that it more likely than not that the in-service sexual assault and being taunted and ridiculed several years after the assault led to the development of social phobia. He also opined that the Veteran's service aggravated his depressive disorder beyond the course of its natural trajectory. He indicated that his opinion differed substantially from the November 2011 VA examiner's opinion, noting that the Veteran had reported in multiple contexts the high level of anxiety he experienced during his service due in part to the sexual assault and the harassing and isolative behavior afterwards. He reported that he had panic attacks in service, and required accommodations in a college classroom shortly after leaving service. There was little evidence of a good response to treatment during service, and resulted in his 2007 report that he was no better or worse despite regular group and individual therapy and medication. Dr. L. also noted that the treatment records that establish the onset of social phobia and panic attacks in 2005 do so in the absence of knowledge of what truly happened in service and do not reflect or consider the substantial component of sexual assault, shame, and emotional trauma he encountered in service. Dr L. noted that these records missed substantial clues as to the development of the anxiety across the years. While it was true that depression was not present at discharge, objective and subjective evidence indicated that the depression had reemerged as the result of the severity of the social phobia symptoms and resultant failures in the Veteran's life attributable to his service. As noted above, the Veteran has been diagnosed with several psychiatric diagnoses. However, there is evidence that some of these disabilities existed prior to service. While no records are available, a private facility has confirmed that the Veteran was hospitalized in 1991. The Veteran has stated that this treatment was for psychiatric symptoms and specifically depression. The appellant is clearly competent to report that he had been treated, hospitalized, and diagnosed prior to service. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Every Veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C.A. § 1111. In this case, when the Veteran was examined at entry, no psychiatric abnormalities were noted. While a notation of depression was given, it was then crossed out. Consequently, the Veteran is presumed to have been sound at the time of entry into service. Determination of the existence of a pre-existing condition may be supported by contemporaneous evidence, or recorded history in the record, which provides a sufficient factual predicate to support a medical opinion, see Miller v. West, 11 Vet. App. 345, 348 (1998), or a later medical opinion based upon statements made by the Veteran about the pre-service history of his/her condition. Harris v. West, 203 F.3d. 1347 (Fed. Cir. 2000)). The burden is on VA to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. See Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). See also Wagner v. Principi, 370 F.3d 1089, 1094-96 (Fed. Cir. 2004). A pre-existing disease will be presumed to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered aggravation in service unless the underlying disability, as opposed to the symptoms of that disability, has worsened. Beverly v. Brown, 9 Vet. App. 402, 406 (1996) (citing Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991)). Clear and unmistakable evidence (obvious and manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b). On the matters of whether the Veteran has an acquired psychiatric disorder that was incurred in or aggravated by service, there are many opinions of record, both from the Veteran and from various healthcare providers. With regard to the Veteran's stated opinions, he is certainly competent to provide evidence with regard to that which he experiences, including his symptomatology and its history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Furthermore, in many cases, laypersons are competent to provide opinions with regard to diagnosis and etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, in this case, on the questions of whether specific diagnosed disabilities existed prior to service and aggravated by service, the Board finds that the conclusions and opinions provided by medical professionals are more probative than the Veteran's post-service lay assertions. The medical and mental health professionals have training, experience, and expertise that render their opinions in this matter more probative than the Veteran's, since he is not shown to have any medical or psychiatric training or expertise. First, the Board finds that the opinion provided in December 2005 VA examiner is afforded little if any probative weight. That examiner provided an opinion that a psychiatric disorder was not incurred in or aggravated by service but limited the rationale to whether the Veteran experienced war zone duty or extreme stress during service. This rationale does not consider any other potential causes or aggravations of psychiatric disability, as they may be caused by things other than war zone duty and extreme stress. Therefore, this opinion is afforded only very little probative weight. Likewise, the Board finds that the opinion provided by the August 2009 VA examiner is afforded only little probative weight. First, while the examiner commented that symptoms of depression and bipolar disorder began at age 17, he did not opine as to whether there was clear and unmistakable evidence that the disorders associated with these symptoms existed prior to service. In addition, he was unable to state whether either of these worsened during service. Finally, this examiner provided no opinion with regard to whether social phobia with anxiety was incurred in or aggravated by service. Given these inadequacies, the Board finds that this opinion is afforded only very little probative weight. The Board acknowledges the opinion provided in November 2009 by the head of psychology of the Veteran's college but finds that it contains little probative weight. He stated that he spoke to the Veteran on several occasions regarding his anxiety and depression, which he experienced as a result of service. However, this opinion contains no reference to whether any disability existed prior to service, and there is no rationale contained in this decision. Therefore, it is afforded little probative weight. Likewise, the Board finds that the second opinion provided in November 2011 by a VA examiner contains only a bare conclusion that is not supported by any kind of reasoned rationale. The examiner simply gives an opinion without explaining why that opinion is supported by the evidence in the record. As such, this opinion and report and afforded only little probative weight. A medical opinion must support its conclusions with analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions [without reasoning or rationale]." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 18, 22 (2007). The Board also notes the written statement and opinion provided in March 2013 by the Veteran's treating social worker. The social worker acknowledges in this statement that he has not reviewed the Veteran's service records. However, the absence this review does not automatically cause the probative weight of an opinion to be diminished, see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008), and as pointed out in the Joint Motion for Remand, the social worker had demonstrated knowledge of the Veteran's past treatment history. For example, in an October 31, 2006, VA psychiatry note, the VA social worker discussed Veteran's hospitalization at the age of 17 before he entered the Marine Corps, and discussed the Veteran's in-service mental health treatment, noting that he had been psychiatrically evaluated and prohibited from doing certain things, such as firing weapons. In a March 23, 2007, note, the same social worker stated that Veteran "was able to provide a copy of his military psychological evaluation," and he later noted that he had discussed the Veteran's history of sexual assault in service. However, while the social worker appears to have had knowledge of the Veteran's mental health history and in-service experiences without the benefit of review of the claims file, he does not cite to any of this history or provide any medical rationale in providing his opinion to the effect that the Veteran's emotional impairment characterized by major depression, panic disorder and generalized anxiety disorder was exacerbated, if not existent, from service. The opinion contains no reference to whether any disability existed prior to service, and there is no discussion as to what factors in the Veteran's pre-service, in-service, and post-service mental health history and service experiences he believes caused the disability to have its onset in or was aggravated in service. Therefore, it is also afforded little probative weight. Furthermore, to the extent that the Veteran's social worker discusses the Veteran's allegation of military sexual trauma, he only relates that he has seen such incidents pervade a sense of self and identity in other veterans and that might be the case here. A medical opinion, such as this one, 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). This opinion does not address the Veteran specifically and provides only a speculative conclusion. Moreover, to the extent that there is a report of military sexual trauma, there is no diagnosis of PTSD. In addition, with regard to the Veteran's social worker suggesting that exposure to chemical neurotoxins during service accounted for the paradoxical effects witnessed when he had been prescribed psychiatric medications, there is absolutely no basis in the Veteran's service records for this allegation, and it is afforded no probative weight. As such, the March 2013 opinion, as a whole, is afforded little probative weight. The Boards notes that the December 2014 social worker statement does not provide an opinion with respect to whether any acquired psychiatric disorder preexisted service and was aggravated therein. The remaining opinions of record are the March 2010 VA examination addendum, the first November 2011 VA examiner's opinion, and the December 2011 VA examiner's opinion. The Board finds that these are the most probative opinions of record for the following reasons. The March 2010 and December 2011 opinions contain one inaccuracy that slightly lowers their probative value. Both examiners indicate or imply that the Veteran was administratively separated from service or separated due to his inability to adapt. However, a review of the Veteran's service records shows that this is not the case. While he was recommended for separation when he was first psychiatrically examined in July 1997, he was instead afforded psychiatric treatment while in service. After one year of such treatment, it was determined that no further counseling was necessary, and the Veteran served out the remainder of his term. While it is not completely clear whether this incorrect assumption factored into the examiners' opinions, it is certainly possible. As such, the most accurate and probative opinion of record is the first one provided in November 2011 by a VA examiner. This examiner distinguished between the Veteran's variously diagnosed acquired psychiatric disorders and provided reasoned opinions, based upon facts contained in the record. He determined that depression existed prior to service and was not aggravated therein. The rationales provided in this opinion are consistent with the record and based on the facts of the case. As this is the most probative opinion, the Board finds that the evidence of record supports a finding that a depressive disorder clearly and unmistakably existed prior to service and clearly and unmistakably was not aggravated therein. As stated above, the VA examiner in November 2011 supported these findings with facts contained in the record, such as the evidence showing that the Veteran was hospitalized prior to service and successful during the remainder of his service career following psychiatric treatment. This conclusion was also supported by the absence of hospitalization and the good response to treatment during service. More specifically, in August 1998, there was a report that the depression had improved and was not currently a problem. Although he reported a history of depression or excessive worry at separation, the evaluation as normal. Cumulatively, the evidence establishes that there had not been a permanent increase in service. Here, a depression disorder clearly and unmistakably was not aggravated in service. The Board acknowledges the December 2014 opinion from private psychologist Dr. L. indicating his belief that it is more likely than not that the Veteran's service aggravated his depressive disorder beyond the course of its natural trajectory. He expressed his opinion that, while depression was not present at the time of discharge from service, the objective and subjective evidence indicates that the depression had reemerged as a result of the severity of the social phobia symptoms. However, this opinion is inconsistent with the Veteran's contemporaneous service treatment records and findings after service, as noted above. While Dr. L. expressed that objective factors supported his opinion, he does not point to any examples in the record and even acknowledges that depression was not noted at discharge. As such, this opinion is of little probative value in assessing whether the Veteran's preexisting depression was aggravated beyond the normal progression as a result of service. As regards the Veteran's anxiety disorder and panic disorder with claustrophobia/agoraphobia and social phobia, the Board notes that there is again conflicting evidence as to the onset of this disability. In a February 2006 opinion, the Veteran's treating psychiatrist noting that "as the Veteran's history was developed, it became apparent that his struggles with panic disorder dated back to his time in the Marine Corp." He noted that the Veteran described worsening panic attacks, anticipatory anxiety, and phobic avoidance that began to impair his ability to function, and gave specific examples of being unable to receive awards in formation or teach class while in the Marines secondary to his symptoms. This opinion was reiterated in a May 2007 statement. In a December 2014 statement, Dr. L. opined that that the Veteran's social phobia is related to service, and in particular the sexual assault and subsequent harassment. In the December 2014 statement, the treating social worker opined that the Veteran's panic disorder and generalized anxiety disorders are related to his service. However, the November 2011 examiner found that all of the anxiety disorders began following service in 2005 and had no relationship to service. He noted that in-service evidence that shows that there was no anxiety disorder manifested during service. In this case, the Board again finds the November 2011 report to the effect that that the Veteran's anxiety disorders began following service in 2005 and had no relationship to service more probative. This opinion was supported by an accurate review of the in-service evidence that shows that there was no anxiety disorder manifested during service. The first November 2011 VA examiner's opinion is adequate and competent and, given, the accurate and well-reasoned conclusions contained therein, the most probative evidence of record on whether an anxiety disorder began in service. As discussed in the Joint Motion for Remand, the Board has considered the February 2006/May 2007 private opinion placing the onset of anxiety and panic disorder in service. The Board has also considered the December 2014 psychologist opinion from Dr. L. indicated that the diagnosis of social phobia is related to service, as well as the December 2014 social worker statement relating the Veteran's anxiety to service. However, the Board again finds these opinions of little probative value. In so finding, the Board notes that the opinions are not consistent with the Veteran's service treatment records and post-service treatment records. While the February 2006/May 2007 examiner, the social worker's statement, and Dr. L. all note that the Veteran's described panic attacks and symptoms of anxiety in service, such complaints are not discussed in the Veteran's treatment history in service, notwithstanding the checking of a box noting depression or excessive worry. Moreover, initial treatment records dated in 2005 document recent onset of social phobia, panic attacks, and claustrophobia. In addition, these opinions are based largely on an inaccurate and inconsistent history as provided by the Veteran. In considering this lay evidence, the Board notes that the Veteran is clearly competent to report that he experienced symptoms of anxiety and social phobia, claustrophobia/agoraphobia in service. However, the post-service reports are inconsistent with the manifestations noted in service. Far more probative are the initial treatment records dated in 2005 establishing recent onset of social phobia and panic attacks. In addition, on treatment in August 2005, the Veteran reported that his symptoms improved while in service. While the February 2006 examiner noted that the Veteran reported that his anxiety impaired his ability to function and hampered his ability to perform and receive awards in service, at other times the Veteran has reported that he "excelled" while in the Marines and left with an unusually high rank. Regarding obsessive compulsive disorder, it was reported that within the past year, he had begun to experience intrusive thoughts. Such evidence provided for treatment purposes, is far more probative than a revised recounting of in-service manifestations. We find the revised recounting to be not credible, and a medical opinion based upon an inaccurate history to be equally inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). The Board has also considered the Veteran's statements to the effect that his current psychiatric disorder stem from his service experiences, to specifically military sexual trauma as a result of a hazing-type incident in service. Again, he is competent to report his in-service experiences, though this incident was not specifically documented in service records. Regardless, the Board finds that the probative value of the lay assertions are outweighed by the specific, reasoned opinion of the November 2011 VA examination report and the clinical evidence of record, which includes the Veteran's various written statements and examinations reports discussing the incident. The November 2011 VA examiner, in determining that the Veteran's psychiatric disorders are primarily unrelated to his service, is entitled to greater probative weight than the lay assertions of the Veteran, even assuming those lay assertions were competent. As such, the Board concludes that while depression clearly and unmistakably existed prior to service and was not aggravated therein, and the Veteran's acquired psychiatric disorder characterized as anxiety and panic disorder with claustrophobia/agoraphobia was not incurred in or aggravated by service. The Board notes that there is no lay or medical evidence of a diagnosis of posttraumatic stress disorder. As such, consideration of the Veteran's claim under the criteria of 38 C.F.R. § 3.304(f) is not warranted. To the extent that the Veteran was diagnosed during or since service as having a personality disorder, the Board notes that personality disorders are not diseases or injuries within the meaning of VA law. See 38 C.F.R. § 3.303, 4.9, 4.127. In sum, as the Veteran's depression clearly and unmistakably existed prior to service and was not aggravated therein, service connection for depressive disorder is not warranted. The Board also finds that the preponderance of the evidence is against the claim for service connection for anxiety disorder and panic disorder with agoraphobia/claustrophobia or other acquired psychiatric disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Service connection for an acquired psychiatric disorder is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs