Citation Nr: 1752219 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 14-01 926 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Whether new and material evidence has been received to reopen service connection for bipolar disorder, and if so, whether service connection is warranted. REPRESENTATION Appellant represented by: Jan Dils, Attorney WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD S. Moore, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty in the U.S. Army from July 1984 to May 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision from the RO in Columbia, South Carolina, which declined to reopen service connection for bipolar disorder, finding that new and material evidence had not been received since a prior final decision. A December 2013 Statement of the Case (SOC) subsequently reopened the claim and denied service connection for bipolar disorder on the merits. This matter was first before the Board in July 1987, where the Board denied service connection for bipolar disorder, finding that bipolar disorder preexisted service and there was no increase in severity of the condition during service (no aggravation). Since issuance of the Supplemental Statement of the Case (SSOC) in May 2016, additional evidence has been received by the Board. The Veteran explicitly waived consideration of new evidence by the RO pursuant to 38 U.S.C. § 7105(e) (West 2012) and 38 C.F.R. § 20.1304 (2017). As such, the Board may consider this evidence in the first instance. In February 2017, the Veteran testified at a Board videoconference hearing in Columbia, South Carolina, before the undersigned Veterans Law Judge (VLJ). The hearing transcript has been associated with the record. The instant matter is a Veterans Benefit Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to insure a total review of the evidence. FINDINGS OF FACT 1. A final July 1987 Board decision denied service connection for bipolar disorder, finding that bipolar disorder preexisted service, and there was no increase in the severity of the condition during service. 2. A June 2010 RO rating decision denied reopening of service connection for bipolar disorder, finding that the evidence submitted was not new and material. The Veteran did not timely file a notice of disagreement (NOD) following the June 2010 rating decision, and new and material evidence was not received during the one year appeal period following that decision. 3. New evidence received since the June 2010 rating decision relates to unestablished facts of whether the current bipolar disorder preexisted service and worsened during service that is necessary to establish service connection for bipolar disorder. 4. The Veteran is currently diagnosed with bipolar disorder. 5. The bipolar disorder clearly and unmistakably preexisted entry into active duty service. 6. The preexisting bipolar disorder clearly and unmistakably did not worsen beyond its natural progression during service. CONCLUSIONS OF LAW 1. The July 1987 Board decision denying service connection for bipolar disorder became final on July 29, 1987, the date stamped on the decision. 38 U.S.C. § 7104 (West 2012); 38 C.F.R. § 20.1100 (2017). 2. The June 2010 rating decision denying reopening of service connection for bipolar disorder became final. 38 U.S.C. § 7105 (West 2012); 38 C.F.R. §§ 20.302, 20.1103 (2017). 3. Evidence received since the June 2010 rating decision is new and material to reopen service connection for bipolar disorder. 38 U.S.C. § 5108 (West 2012); 38 C.F.R. § 3.156 (2017). 4. Bipolar disorder clearly and unmistakably preexisted service. 38 U.S.C. § 1111 (West 2012); 38 C.F.R. § 3.304 (2017). 4. The preexisting bipolar disorder clearly and unmistakably was not aggravated by service. 38 U.S.C. § 1111 (West 2012); 38 C.F.R. § 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). The United States Court of Appeals for Veterans' Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. VA is required to provide notice of the information and evidence "not previously provided to the Secretary that is necessary to substantiate the claim." 38 U.S.C. § 5103(a)(1). In claims to reopen, this requires VA "to explain what 'new and material evidence' means." Akers v. Shinseki, 673 F.3d 1352, 1358 (Fed. Cir. 2012). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that 38 U.S.C. §§ 5103(a)(1) and 3.159(b)(1) do not require case specific notice of the information and evidence necessary to cure the deficiencies of the previously denied claim. Instead the notice requirements are satisfied by generic notice of the evidence necessary to substantiate the particular type of claim being asserted after an initial claim for benefits has been filed, that is, generic notice of the evidence necessary to reopen a claim in this matter. See Wilson v. Mansfield, 506 F.3d 1055, 1059-60 (Fed. Cir. 2007); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009); see also VAOPGCPREC 6-2014. In the August 2012 VCAA notice letter sent prior to the initial denial of the claim, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation benefits, and described the types of information and evidence the Veteran needed to submit to substantiate the claim. The RO explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claim. The RO informed the Veteran how VA determines the disability rating and effective date once service connection is established. The RO informed the Veteran of the definitions of new and material evidence with respect to reopening the claim. The RO informed the Veteran that the claim was previously denied because the evidence failed to show that the preexisting bipolar was aggravated by military service. As such, the Board finds the August 2012 notice letter satisfied the notice requirements. Regarding the duty to assist, the RO has secured the Veteran's service treatment records, service personnel records, and Social Security Administration (SSA) records. The RO has associated with the claims file previously secured VA treatment records, SSA records, and private treatment records as authorized by the Veteran. The Veteran has submitted private treatment records and medical opinions from private mental health professionals. The Veteran was afforded a VA psychological examination and opinion in December 2013, which addressed whether the current psychiatric condition preexisted service and worsened beyond the normal progression by service. See 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). As will be discussed below, when considered as a whole, the VA examination and opinion was thorough, supported by explanations, based on a review of accurate facts including from the claims folder, and supported by clinical evidence of record. The VA examination also considered the Veteran's lay statements. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As such, there is no basis for any further VA examination or opinion as to the particular issue on appeal. As noted above, the Veteran also was afforded a hearing in February 2017 before the undersigned VLJ during which he presented oral argument in support of his claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the VLJ or Decision Review Officer who chairs a hearing to fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the VLJ identified the issue on appeal during the hearing; advised that new and material evidence was required to reopen bipolar disorder; and advised that the claim was previously denied on the basis of a pre-existing disability that was not aggravated by service. The VLJ obtained information concerning the Veteran's symptoms, diagnoses, and the specifics of his contentions, including symptoms prior to service; and suggested the submission of evidence that would be beneficial, particularly the submission of SSA records in his possession that are relevant to the claim. Significantly, neither the Veteran nor the representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has the Veteran or representative identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim. The Veteran submitted a letter from SSA that informed that in 2013 SSA requested the disability folder in their electronic storage system; however, as the SSA disability claim was filed in 1987 it is very likely that folders dating back to that date are destroyed. As previously noted, the RO associated previously secured SSA records dated from 1985 to 2002 with the claims file and associated updated SSA records with the claims file in January 2013. Establishing service connection in the instant matter would require evidence that either a) the bipolar disorder did not preexist service, or b) that preexisting bipolar disorder was aggravated by active duty service. SSA records from 2013 forward would not be relevant in substantiating preexistence of bipolar disorder or aggravation of a preexisting bipolar disorder in service, as the DD Form 214 reflects active duty service from July 1984 to May 1985. See 38 U.S.C. § 5103A (a)(2) (VA "is not required to provide assistance to a claimant... if no reasonable possibility exists that such assistance would aid in substantiating the claim"); see also Golz v. Shinseki, 590 F.3d 1317, 1321-22 (Fed. Cir. 2010) (holding the duty to assist does not require VA to obtain SSA records where there is no reasonable possibility that the records are relevant to the veteran's claim). Therefore, the Board finds the duty to assist with regards to securing relevant SSA records has been satisfied. All relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the record as to the issue on appeal. Any duties imposed on VA, including the duties to assist and to provide notification, have been met as set forth above. Reopening Service Connection for Bipolar Disorder Generally, a claim which has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C. § 7105. However, pursuant to 38 U.S.C. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is "new and material," the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly received evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id at 118. Regardless of the RO's determination as to whether new and material evidence had been received, the Board must address the issue of the receipt of new and material evidence in the first instance because it determines the Board's jurisdiction to reach the underlying claims and to adjudicate the claims de novo. See Woehlaert v. Nicholson, 21 Vet. App. 456, 460-61 (2007) (citing Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996)). If the Board determines that the evidence submitted is both new and material, it must reopen the case and evaluate the claim in light of all the evidence. Justus, 3 Vet. App. at 512. Such evidence is presumed to be credible for the purpose of determining whether the case should be reopened. Once the case is reopened, the presumption as to the credibility no longer applies. Id at 513. A July 1987 Board decision denied service connection for bipolar disorder based on a preexisting bipolar disorder that was not aggravated by military service. The July 1987 Board decision became final on July 29, 1987, the date stamped on the decision. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. A June 2010 rating decision denied service connection for bipolar disorder, finding that the evidence received in support of the claim was not new and material, as it did not show the psychiatric condition was worsened due to military service, that is, that the condition was aggravated by military service. The Veteran did not file a timely NOD following the June 2010 rating decision, and no new and material evidence was received during the one year appeal period following the decision. As such, the June 2010 rating decision became final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(a), (b), 20.302, 20.1103. Since the June 2010 rating decision denying service connection for bipolar disorder, VA has received additional medical evidence. An October 2012 medical opinion from a private consulting psychologist opined that bipolar disorder did not preexist service and that the Veteran had his first bona fide manic episode in-service. A treating psychiatrist in April 2013 opined that it is possible that being forced to stay in the military for a few months might have exacerbated the Veteran's preexisting bipolar disorder and led to a suicide attempt and hospitalization in service. When the credibility of such evidence is presumed for the purposes of reopening the claim, such evidence relates to unestablished facts of the non-preexistence of bipolar disorder and aggravation of the preexisting bipolar disorder during service, so could reasonably substantiate the issue of service connection for a psychiatric disorder. For this reason, the Board finds that the additional evidence is new and material to reopen service connection for bipolar disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection for Bipolar Disorder Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). As discussed in detail below, the Board has found that the Veteran's bipolar disorder clearly and unmistakably preexisted active duty service, and clearly and unmistakably was not aggravated by service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304. Accordingly, the direct service connection provisions of 38 C.F.R. § 3.303(a), (d) and presumptive service connection provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 do not apply in this case. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). Where such defects, infirmities or disorders are not noted when examined, accepted, and enrolled for service, pursuant to 38 U.S.C. § 1111 and 38 C.F.R. § 3.304, in order to rebut the presumption of soundness on entry into service, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-03. In explaining the meaning of an increase in disability, the Court has held that "temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered 'aggravation in service' unless the underlying condition, as contrasted to symptoms, is worsened." Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). However, the increase need not be so severe as to warrant compensation. Browder v. Derwinski, 1 Vet. App. 204, 207 (1991). The Veteran need not produce any evidence of aggravation in order to prevail under the no-aggravation prong of the presumption of soundness. Rather, the burden is on VA to establish by clear and unmistakable evidence that it was not aggravated or that any increase in severity was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). "The Federal Circuit has made clear that the Secretary may rebut the second prong of the presumption of soundness through demonstrating, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was due to the natural progression of the condition." Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009) (citing Wagner, 370 F.3d at 1096). This burden must be met by "affirmative evidence" demonstrating that there was no aggravation. See Horn, 25 Vet. App. at 235. Conversely, the burden is not met by finding "that the record contains insufficient evidence of aggravation." Id. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The Veteran contends that he did not have a preexisting psychiatric disorder, and that bipolar disorder either originated in or was aggravated by the July 1984 to May 1985 period of active service. The Veteran has reported and testified that pouring lighter fluid on himself and striking a match at age 13 was not a suicide attempt, that a motorcycle accident at age 15 was not a suicide attempt, but he took a half bottle of Tylenol at age 17, but also denies that this was a suicide attempt. The Veteran's representative argues that the Veteran had preexisting depression, but depression was aggravated by service as evidenced by manic episodes during service and suicide attempt that resulted in hospitalization. After a review of all the evidence, lay and medical, the Board finds that the Veteran is currently diagnosed with bipolar disorder. Such diagnosis can be found in the December 2013 VA psychological examination report, the March 1985 service psychiatric evaluation report, and private treatment records dated from 1988 to present. In this case, no psychiatric disorder was "noted" at the May 1984 service enlistment examination because the history the Veteran presented at service entrance did not mention any pre-service symptoms of depression or suicidal ideation or attempt or hospitalization for suicide attempt at age 17. On the May 1984 service enlistment examination report, the Veteran answered "no" to questions regarding a history of attempted suicide and depression, despite his three-week pre-service psychiatric admission for suicidal ideation and a major depressive episode one year prior. No abnormalities or deficits were noted in the psychiatric system upon clinical evaluation during the May 1984 service enlistment examination; therefore, the presumption of soundness attaches, and requires clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service to rebut the presumption of soundness. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. The record reflects clear and unmistakable evidence that bipolar disorder preexisted active duty service. The Veteran's psychiatric history, lay statements made for treatment purposes during psychiatric hospitalization prior to service entrance and during service, and pre-service and in-service psychiatric symptoms and diagnosis show a preexisting bipolar disorder that manifested in multi-year and recurrent depression prior to service, suicidal ideation with three suicidal gestures prior to service, and hospitalization prior to service for suicide attempt. The record reflects that, prior to service, the Veteran was admitted to DeKalb General Hospital for psychiatric treatment on January 7, 1983, at age 17. This occurred one and a half years prior to the July 1984 entrance into service. Clinical data from the pre-service 1983 psychiatric hospitalization reveals that the Veteran reported recurrent depression with suicidal ideation for approximately two years. The Veteran reported a desire to kill himself one to two weeks prior to admission, but he finally took an overdose of Tylenol the day of admission. During the January 1983 pre-service psychiatric hospitalization, diagnosis was of a major depressive episode, rule out other character disorder. The Veteran is competent to relate these pre-service psychiatric symptoms, treatment, and diagnosis, and reported these pre-service symptoms and treatment prior to, during, and subsequent to service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (stating that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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). In March 1985 during service, the Veteran was psychiatrically hospitalized at Dwight D. Eisenhower Army Medical Center in Fort Gordon, Georgia, for a manic episode due to exhibiting bizarre behavior. Clinical data from the March 1985 psychiatric admission reveals that the Veteran reported frequent mood changes which he described as "having highs" and feeling "explosive" and then having periods of depression. The Veteran endorsed suicidal ideation and gestures during periods of depression and reported three previous suicide attempts prior to service, the first occurring at age 13 when he poured lighter fluid on himself and struck a match. The Veteran also reported an intentional motorcycle accident at age 15, and then a psychiatric hospitalization for about three weeks at age 17 after he ingested about 300 extra strength Tylenol tablets. Diagnosis was of bipolar disorder, manic type, acute, manifested, in part, by a history of hospitalization for depression with several suicide attempts. See 38 C.F.R. § 3.304(b)(2) (history of disability should be accorded probative value "consistent with accepted medical evidence relating to incurrence, symptoms and course of the injury or disease, including official and other records made prior to, during or subsequent to service"). An April 1985 service treatment record reflects that the Veteran subsequently attempted suicide in service by lacerating his left wrist with a razor while admitted to Dwight D. Eisenhower Army Medical Center. The medical professionals assessed that this was consistent with a the history of suicide attempts reported prior to service. A May 1985 report from the medical evaluation board (MEB), signed by two medical doctors (MD), conveys the opinion that the Veteran was not qualified for retention due to a preexisting bipolar disorder that was not aggravated by active duty service, and recommended separation from active duty. The Veteran signed a disposition form in May 1985 requesting expeditious discharge with these statements based on the recommendations of the MEB. The DD Form 214 reflects that the Veteran separated from service May 31, 1985. Since separation from service, the record reflects multiple psychiatric hospitalizations between 1988 and 2010 for manic and depressive episodes with multiple suicide attempts. See December 1988, February 1991, July 2010 private treatment records. The Veteran received a VA psychological examination in December 2013. The VA examiner diagnosed bipolar disorder, last episode depressed, in partial remission. The VA examiner thoroughly reviewed the evidence of record, interviewed the Veteran, and examined the Veteran using appropriate medical techniques. At the conclusion of the examination, the VA examiner opined that the Veteran clearly had a psychiatric problem prior to enlistment in the military, reasoning that the Veteran had a psychiatric hospitalization for a major depressive episode with suicide attempt in January 1983 and has a history of multiple depressive episodes and suicide attempts prior to enlistment, and that this pre-service history is consistent with psychiatric hospitalization and suicide attempts noted in service. The Board finds the VA examiner's opinion to be the most probative of record, as the opinion is supported by a thorough rationale based on accurate facts derived from the record; acceptable medical techniques; the relevant pre-service and in-service medical evidence and lay histories; and interview and examination of the Veteran. An unknown author from Aiken Psychiatric and Psychotherapy provided a medical statement in January 2017 that diagnosed bipolar disorder, in remission. The statement was that, although the Veteran has a history of a pre-service depressive episode in his youth, because a depressive episode in a teen or young adult can be the first episode of bipolar disorder, it is impossible to distinguish the depressive episode noted prior to service from the bipolar disorder diagnosed in service. The Board finds this statement to be of no probative value because it has no tendency to distinguish the bipolar disorder during service from the pre-service symptoms or findings of depression; to the contrary, the statement indicates that no such differentiation is possible. The statement even indicates that a depressive episode is one factor or characteristic of the whole impairment of bipolar disorder, which tends to relate episodes of depression and suicidal ideation prior to service to similar symptoms and bipolar symptoms during service. The transcript from the February 2017 Board videoconference hearing reflects that the Veteran testified that prior to service he had no psychiatric or emotional problems, no prior suicide attempts, and no treatment with medications for a psychiatric condition. He testified that the isolated depressive episode prior to service was more of a cry for attention than a psychiatric disability. The Veteran contends that psychiatric symptoms first manifested about five to six months into service due to the stress of being retained in the military, as he requested a training discharge program (TDP) discharge but was thereafter retained in the military following a recommendation for immediate discharge. See February 2017 Hearing Transcript. Similar statements have been made by the Veteran throughout the course of this appeal. The Veteran's recent testimony and statements attempting to deny preexisting psychiatric disability and/or symptoms prior to service are inconsistent with his own prior statements made on multiple occasions prior to, during, and after service that were made for treatment purposes, for purposes of treatment in service, for purposes of treatment after service, and to a VA examiner for VA compensation purposes. Additionally, the Veteran's statement of no psychiatric disability, symptoms, or treatment prior to service is inconsistent with the Veteran's own reported histories as well as with medical evidence of record that reflects a three-week psychiatric hospitalization prior to service in January 1983 with diagnosis of a major depressive episode and treatment that included both psychotherapy and medication. The record reflects the Veteran's own reports of recurrent episodes of depression and suicidal ideation for two years and three suicide attempts prior to service. See January 1983 Private treatment record, March 1985 Service treatment record. For these reasons, the Veteran's recent testimony and statements attempting to deny preexisting psychiatric disability and/or symptoms prior to service are not credible, so are of no probative value. See Cromer v. Nicholson, 19 Vet. App. 215 (2005) (upholding Board denial of service connection and finding that a veteran's recent post-service account of in-service events was not credible because the veteran had previously given other histories and theories that did not mention the alleged in-service event, and first "came up with the story" years after service and in connection with the compensation claim). With regard to the assertion during the appeals process that the pre-service episode of depression was a cry for help and not evidence of a pre-existing psychiatric disorder, including of bipolar disorder, under the facts of this case that include a multi-year history of depressive symptoms prior to service, multiple objective indications of suicidal ideation and attempt prior to service, and hospitalization and treatment with medication prior to service, the Veteran is not competent to diagnose the pre-service symptoms. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness); Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (holding that "PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify"). The Veteran also submitted a psychological evaluation report dated October 2012 from a private psychologist he consulted with regarding his claim; however, the report and purported opinion therein are of no probative value as it is based on materially inaccurate factual assumption of no evidence of bipolar disorder symptoms prior to service. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). In the October 2012 psychological report, the consulting private psychologist opined that bipolar disorder did not pre-exist military service, reasoning that the Veteran had depressive symptoms and disorders before the military, but his first manic symptoms occurred while he was stationed at Fort Gordon. The consulting psychologist provided no rationale as to why the major depressive episode prior to service could not be one characteristic or episode of the larger picture of bipolar disorder. The October 2012 psychological report does not show recognition of the facts of pre-service major depressive episode in January 1983 with associated suicidal attempts, the Veteran descriptions of a history of recurrent depressive episodes with suicidal ideation in January 1983 prior to service, or the history of multiple suicide attempts and continued depressive episodes with suicidal ideation during active duty service. See January 1983 Private treatment record, March 1985 Service treatment record. The private psychologist, in the October 2012 statement, agreed with the VA examiner's reasoning that the Veteran has shown multiple episodes of major depression and an episode of mania prior to and in service, which is the true nature of bipolar disorder. As such, the private psychologist's opinion that the bipolar disorder did not pre-exist service is internally inconsistent with the psychologist's own acknowledgement that bipolar disorder is characterized by both manic and depressive episodes, which are not mutually exclusive episodes of mania or depression. As noted above, the unknown treating mental health professional from Aiken opined in January 2017 that it was impossible to distinguish the 1983 major depressive episode from the bipolar disorder diagnosed in-service, as a depressive episode in a young adult can be the first episode of bipolar disorder. For this reason, the October 2012 purported opinion by the consulting private psychologist is of no probative value, as it stems from an inaccurate factual premise of no pre-service bipolar disorder symptoms. See Reonal, 5 Vet. App. at 461; Swann v. Brown, 5 Vet. App. 229 (1993) (stating that the Board is not bound to accept medical opinions that are based upon an inaccurate factual background). The October 2012 consulting private psychologist's opinion also pertains to an irrelevant question of direct service incurrence, not aggravation of a preexisting disorder during service. The consulting private psychologist opined that the Veteran had a bona fide manic episode that first occurred while he was at Fort Gordon. Once the preexistence of a disorder is established, the issue is one of aggravation (38 U.S.C. § 1111; 38 C.F.R. § 3.304), not direct service connection (38 U.S.C. § 1110; 38 C.F.R. § 3.303(d)). The issue only converts to one for direct service connection if the presumption of soundness is not rebutted. See Wagner, 370 F.3d 1089. For these reasons, and because the presumption of soundness at entry into service is rebutted in this case by clear and unmistakable evidence as to both elements (preexistence and non-aggravation), the purported opinion is based upon an inaccurate factual premise, the purported private opinion on the question of nexus to service is not relevant to the questions of preexistence or aggravation. Having reviewed all the relevant evidence of record, the Board finds that the currently diagnosed bipolar disorder clearly and unmistakable existed prior to service. Concerning the Veteran's recent statements about the state of psychiatric disability prior to service and the purported October 2012 private opinion, the Court has held that the phrase "clear and unmistakable evidence" means that the evidence "cannot be misinterpreted and misunderstood, that is, it is undebatable." Vanerson v. West, 12 Vet. App. 254, 258-59 (1999) (citing definition of "clear and unmistakable error" in Russell v. Principi, 3 Vet. App. 310, 313-14 (1992) (en banc)). It was noted, in essence, that the non-adversarial nature of VA compensation laws made VA's presumption rebuttal burden distinguishable from other evidentiary presumption law theories, but that VA was not precluded from assessing the probative value of the other contrary evidence of record in meeting this burden. The Court held that "[t]he Board is free to reject this evidence if it lacks competency or credibility. Furthermore, the Board may find that the evidence is of such low probative value that it does not affect the 'unmistakability' of the evidence showing preservice inception of the disorder. In short, the Board is not precluded from finding that the condition existed prior to service simply because there is some evidence to the contrary if their findings of fact indicate that the contrary evidence is of no weight or otherwise non-probative. However, the Board must provide reasons and bases for such a finding." Id. at 261-262. As discussed above, the Board has found the Veteran's more recent statements and the October 2012 private opinion based upon inaccurate facts to not be credible and/or probative, and, thus, to have no weight in the Board's determination as to whether there is clear and unmistakable evidence that bipolar disorder existed prior to service. Likewise, the Board has found the purported private medical opinion evidence to be based upon inaccurate factual premises so as to lack probative value regarding differentiation of depression from bipolar symptoms, and to actually have a tendency to associate the pre-service symptoms to diagnosed bipolar disorder so as to actually weigh against the Veteran's claim. As such, the Board has adequately addressed why this evidence does not prevent the Board from finding that the bipolar disorder disability clearly and unmistakably existed prior to service. The evidence in favor of such a finding is so significant as to constitute clear and unmistakable evidence that bipolar disorder existed prior to service. Such evidence includes the Veteran's own statements prior to, during, and after service; the January 1983 hospital report showing that the Veteran was treated for a major depressive episode and suicide attempt prior to service; the service treatment records showing that the Veteran was diagnosed with bipolar disorder that was manifested, in part, by a history of hospitalization for a depressive episode and suicide attempts prior to and during service; and the MEB report opinions by two medical doctors that the bipolar disorder preexisted service (EPTE - existed prior to entry) and was not aggravated by service. Clear and unmistakable evidence of preexistence is further shown by the December 2013 VA psychological opinion that bipolar disorder clearly existed prior to service, and the January 2017 psychological opinion that it is impossible to distinguish the depressive episode prior to service with bipolar disorder and associated symptoms noted in-service. For these reasons, the Board finds that the evidence supports a finding that the Veteran's bipolar disorder disability clearly and unmistakably existed prior to service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. Based upon a review of all the evidence, both lay and medical, prior to, during, and after service, the Board next finds that the evidence demonstrates that the clearly preexisting bipolar disorder clearly and unmistakably was not aggravated by active service. The Board recognizes the high burden placed on VA to establish by clear and unmistakable evidence that the bipolar disorder was not aggravated in service or that any increase in severity during service was due to the natural progression of the disease. Further, the Board recognizes that there must be affirmative evidence demonstrating that there was no aggravation. Horn, 25 Vet. App. at 235. In this case, as will be discussed below, the Board has obtained affirmative competent medical opinion evidence (a retrospective opinion) that the bipolar disorder clearly and unmistakably was not aggravated during service. On the question of aggravation by service, the February 2017 Board hearing transcript reflects that the Veteran reported that he has continued to have waxing and waning symptoms, multiple psychiatric hospitalizations, and he has remained under psychiatric care since separation from service. He reported having "flare ups" of symptoms, which improve when he starts medication; however, he reports that symptoms eventually resurface, as he stops taking his medications when he feels better. The record reflects that the Veteran had a history of multiple suicide attempts and was psychiatrically hospitalized for suicidal ideation and a major depressive episode prior to service in January 1983 during which he reported a two-year history of depression with suicidal ideation. The January 1983 psychiatric report reflects that depressive symptoms and suicidal ideation improved following treatment with Nortriptyline and individual and group milieu counseling. With no additional treatment noted following the 1983 hospitalization, in-service records reflect additional flare ups of symptoms, including reports of continued depressive episodes in service marked by additional suicide attempts, two of which did not come to medical attention, and a report of manic behavior marked by going AWOL, engaging in a spending spree, exhibiting bizarre behavior and homicidal ideation. Clinical data reveals that the Veteran considered taking an overdose during the March 1985 manic episode but decided to "have fun instead." See March 1985 and April 1985 service treatment records. Given the pre-service evidence of a history of depressive episodes with suicide attempts and the in-service evidence of continued episodes of depression with suicide attempts and a manic episode, the record does not reflect that the underlying condition was worsened or aggravated by service. The May 1985 MEB report reflects that Veteran's symptoms improved with the treatment administered, similar to the positive response to treatment noted during the January 1983 psychiatric hospitalization, which is further evidence that the pre-existing bipolar disorder was not worsened or aggravated by service. In addition, the doctors on the MEB opined that the pre-existing psychiatric disorder was not aggravated by service. Since separation from service in May 1985, treatment records from 1985 through 2010 reflect multiple psychiatric hospitalizations for manic and depressive episodes. A December 1985 VA treatment record reflects that the Veteran reported severe mood swings from periods of depression and suicidal ideation for several weeks to periods of elation for several weeks. Of note, the Veteran was not being treated for the psychiatric condition at the time due to lack of finances. Acute admission notes from Elmira Psychiatric Center dated December 1988 and February 1991 also reflect reports of hypomanic behavior with impaired impulse control and judgment, as well as periods of depression and suicidal ideation, similar to symptoms noted during episodes of depression and mania prior to and during service. A July 2001 private note from Tioga County Mental Hygiene reflects that the Veteran had been treated for bipolar disorder on and off for a number of years and recently had a six-day psychiatric admission at Robert Packer Hospital in June 2001 for suicidal ideation that was presumably related to noncompliance with medication, as he was last seen in 1999, after which he went off medications. An October 2002 SSA record reflects that the Veteran reported that all of his hospitalizations occurred following noncompliance with pharmacotherapy. Aiken Psychiatry and Psychotherapy notes reflect that bipolar disorder has been stable with medications such as Depakote and Effexor from 2010 through 2013, and the condition remained relatively stable with psychotherapy from 2014 through 2017 while not on medication; however, the Veteran was advised of the potential for a recurrence of symptoms without medication. The longitudinal medical records reflect a history of episodes of depression with suicide attempts prior to service, and continued episodes of depression with suicidal ideation and some episodes of mania during and after active duty service, which stabilize with treatment such as medication management and/or psychotherapy as noted above. The Veteran has submitted statements from private treating mental health personnel concerning the current bipolar disorder. In these statements, dated April 2013 and January 2017, the mental health providers noted evidence of psychiatric problems prior to service and opined that, given the Veteran's report of experiencing stress due to being retained in the military, it is reasonable to consider the possibility that being retained in the military might have exacerbated or could have precipitated the bipolar disorder and led to the in-service psychiatric hospitalization. In a separate January 2017 medical statement, the unknown author from Aiken Psychiatric and Psychotherapy similarly wrote that the stress of the Veteran's military experience may have precipitated a manic episode; however, the author was unable to assess the severity of the illness in terms of in-service aggravation, reasoning that bipolar disorder waxes and wanes and the condition was currently in remission. While April 2013 and January 2017 private opinions suggests a possibility of an exacerbation of bipolar disorder by service, when the language and context of the statements are considered, the purported opinions are of no probative value as they are statements of mere possibility rather than probability. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (a letter from a physician indicating that the veteran's death "may or may not" have been averted if medical personnel could have effectively intubated the veteran was held to be speculative); Bloom v. West, 12 Vet. App. 185, 186-187 (treating physician's opinion that service "could have" precipitated a disability found too speculative); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (the Court found evidence favorable to the veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a physician's statement that the veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis also implied "may or may not" and was deemed speculative); and Bostain v. West, 11 Vet. App. 124, 128 (1998) (the Court held that a physician's opinion that an unspecified preexisting service-related condition "may have" contributed to the veteran's death was too speculative to be new and material evidence). For the above mentioned reasons, the Board finds these opinions to be of no probative value, as they as they are statements of possibility that are speculative in nature. 38 C.F.R. § 3.102 (evidence involving speculation or remote possibility does not show probability). The October 2012 consulting psychologist's statement discussed above purports to be a direct service connection opinion rather than aggravation opinion, so is irrelevant on the question of whether bipolar disorder was "aggravated by" service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. The VA examiner, in the December 2013 VA psychological examination report, extensively reviewed the available evidence of record, including the medical evidence. After reviewing all of the relevant evidence, the VA examiner opined that there is no indication from the claims file or service treatment records that military service aggravated or altered the course of the Veteran's psychiatric condition. The VA examiner reviewed accurate facts from the claims file and considered the Veteran's lay statements regarding in-service psychiatric symptoms. The VA examiner cited to evidence of three suicide attempts and depressive episodes for a couple years prior to service, and the hospitalization for a major depressive episode prior to service in January 1983. The VA examiner also noted evidence of continued reports of depressive episodes and suicidal ideation in service, the hospitalization for a manic episode and suicide attempt in service, as well as multiple hospitalizations for episodes of depression, mania, and suicidal ideation subsequent to service with positive response to treatment. Having considered the Veteran's history of suicide attempts and depressive and manic episodes prior to, during and after service, the VA examiner noted that this is the nature of bipolar disorder, and opined that military service did not aggravate or alter the course of the Veteran's preexisting psychiatric condition. While the VA examiner did not use the phrase "clear and unmistakable" with respect to whether the preexisting bipolar disorder was aggravated by service, the rationale clearly demonstrates that the Veteran had a preexisting psychiatric disability that was not aggravated by service, based on the evidence of a psychiatric hospitalization and depressive episodes with multiple suicide attempts prior to service, psychiatric hospitalization for a manic episode in service with suicide attempt during admission, reports of continued depressive episodes and additional suicide attempts in service that did not come to medical attention, and continued manic and depressive episodes after service without evidence of in-service aggravation. Moreover, the question of whether the evidence is clear and unmistakable in this case is an adjudicative question, a legal standard that is decided by the Board. While the Board has considered and weighed all evidence, including the VA examiner's opinion, on the questions of preexistence and aggravation, the strength of a medical professional's opinion, including the wording of that opinion, is evidence to be considered, but is not determinative; rather, the Board makes such adjudicative findings after weighing all evidence of record. While the VA examiner did not use the term "clear and unmistakable," the Board finds that it is undebatable that the examiner assessed that the instances of in-service treatment for bipolar disorder did not represent an aggravation of the psychiatric disability, but instead merely the natural progression of the preexisting psychiatric disability. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293-294 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)). Having reviewed all the evidence of record, lay and medical, the Board finds that there is clear and unmistakable evidence that bipolar disorder was not aggravated by active service, as there was no increase in disability during service beyond that due to the natural progression of the bipolar disorder. See Wagner, 370 F.3d at 1096. Specifically, the evidence reflects that the Veteran's various psychiatric symptoms waxed and waned both prior to and during service. In the December 2013 VA opinion, the VA examiner explained that the medical evidence prior to service reflected that the Veteran's psychiatric disability symptoms were clearly present prior to service, noting the January 1983 psychiatric admission for a depressive episode and suicidal ideation, in addition to recurrent problems with depression and suicidal ideation prior to service. While the Veteran had a psychiatric admission for a manic episode and suicide attempts in service, the evidence does not reflect that the in-service symptoms were greater than the pre-service symptoms, which included depression, suicide attempts, and hospitalization prior to service. Further, the Veteran testified that he has continued to have waxing and waning symptoms immediately after and for several years following service, noting that his symptoms did not stabilize until he received regular treatment. The VA examiner indicated that bipolar disorder is currently in remission with treatment. The VA examiner acknowledged a history of multiple episodes of major depression and mania, noting that this is the nature of bipolar disorder. As such, the VA examiner's opinion is strong evidence that the preexisting bipolar disorder did not worsen during service. For these reasons, the Board finds the lay and medical evidence clearly and unmistakably demonstrates that the Veteran's preexisting bipolar disorder was not aggravated by service, that is, did not worsen beyond a natural progression in or during active service. Accordingly, service connection for bipolar disorder is not warranted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. ORDER New and material evidence having been received, the appeal to reopen service connection for a bipolar disorder is granted. Service connection for bipolar disorder is denied ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs