Citation Nr: 9922376 Decision Date: 08/10/99 Archive Date: 08/24/99 DOCKET NO. 93-06 321 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a sinus disorder. 3. Entitlement to service connection for a back disorder. 4. Entitlement to service connection for a left hip disorder. 5. Entitlement to service connection for a left leg disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michelle L. Nelsen, Associate Counsel INTRODUCTION The veteran had active duty from October 1989 to March 1990 and from January 1991 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The claims folder was subsequently transferred to the RO in Chicago, Illinois. The veteran failed to appear for a hearing before a member of the Board scheduled in June 1993. The case returns to the Board following a remand to the RO in December 1994. In the December 1994 remand, the Board referred to the RO the issue of entitlement to service connection for a left heel disorder. There is no indication in the claims folder that such issue was developed or adjudicated. The matter is again referred to the RO for the appropriate action. The issues of service connection for a sinus disorder, and disorders of the back, left hip, and left leg are addressed in the REMAND portion of the decision. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for the equitable disposition of the veteran's appeal. 2. Medical evidence clearly and unmistakably establishes the existence of a psychiatric disorder prior to service. 3. The evidence fails to reveal any increase in severity of the psychiatric disorder during active military service. 4. The veteran is currently diagnosed with psychiatric disorders including PTSD. 5. The claimed in-service stressor is not related to combat. 6. The occurrence of the veteran's claimed in-service stressor is not supported by credible corroborating evidence. CONCLUSIONS OF LAW 1. The veteran's preexisting psychiatric disorder was not aggravated during active military service. 38 U.S.C.A. §§ 1110, 1111, 1153, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306(a) (1998). 2. PTSD was not incurred during active military service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (1998); 64 Fed. Reg. 32,807-32808 (1999) (to be codified at 38 C.F.R. pt. 3); VA Adjudication Procedure Manual M21-1, Part III, paragraph 5.14c (Feb. 20, 1996); VA Adjudication Procedure Manual M21-1, Part III, paragraph 7.47c(2) (Oct. 11, 1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board finds that the veteran's claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102 (1998). See Murphy v. Derwinski, 1 Vet. App. 78, 91 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented a claim which is not implausible when her contentions and the evidence of record are viewed in the light most favorable to the claim. The Board is also satisfied that all relevant facts have been properly and sufficiently developed to address the issue at hand. Factual Background Records from Porter-Starke Services showed that the veteran was hospitalized in November and December 1986. The psychological evaluation revealed that she had been previously admitted in January 1986. The diagnosis at that time was chronic, residual undifferentiated schizophrenia, a brief and acute exacerbation, with an Axis II diagnosis of borderline features. The precipitants were marital separation and the stress of going to college. Currently, the veteran was referred by Dr. Schultz for depression and anxiety. During the current presentation, the veteran's mental status was much better, without any overt signs of psychosis or evidence of cognitive of perceptual distortions, depression, or anxiety. The precipitants to the admission were pregnancy, a shaky marriage, and going to college. She had been seeing Dr. Schultz for nearly a year. She continued to fixate on her nose surgery at age 15, "when all her troubles began," and to endorse beliefs that there was something wrong with her mind, that she was condemned, that she had very strange experiences. She repressed much hostility and became passive-aggressive. The diagnosis was chronic, residual schizophrenia in remission phase with passive-aggressive personality disorder. The discharge summary indicated a final diagnosis of dysthymic disorder with no Axis II diagnosis. The prognosis was guarded as she appeared to gain little insight while hospitalized. The veteran enlisted in the Army Reserves in June 1989. On the June 1989 Applicant Medical Prescreening Form, the veteran denied ever being treated for a mental condition. The June 1989 enlistment examination report revealed no psychiatric abnormality. The veteran did not report any prior psychiatric treatment or hospitalization on the report of medical history. In January 1991, during an evaluation for overseas deployment, the veteran related that she had a history of psychiatric illness requiring hospitalization and was on Prozac. Notes dated several days later in January 1991 revealed that the veteran complained of severe anxiety and confusion, but was not suicidal. She had a history of a psychiatric disorder. The report of the March 1991 examination did not reveal any psychiatric abnormality. On the report of medical history, the veteran reported a history including depression or excessive worry. The veteran submitted a March 1991 consultation report from Frank P. Brognog, Ph.D., a clinical psychologist. Dr. Brognog stated his opinion, based on clinical interview, diagnostic inventory, and intermittent professional contact over the previous 20 years, that the veteran did not appear to be suffering from any severe clinical syndrome at the psychological level of functioning. She was very concerned about being discharged. She also reported a recent period of high anxiety and depression because of her husband's heart attack, her mother's serious illness, and recently losing her job. Dr. Brognog indicated that he had known the veteran for several years as a patient and she had made great progress over the years in all major life areas. During the June 1991 VA psychiatric examination, the veteran related a history of anxiety and depressive disorders since age 16, including three psychiatric hospitalizations as a teen for anxiety and depressive symptoms. She was trained in psychology as a counselor. Mental status examination was normal. The diagnosis was generalized anxiety disorder by history. The veteran testified at a personal hearing in August 1992. She stated that when she was a teenager she played games to get attention. She was a college graduate with a degree in criminal justice and psychology. The veteran related that she was sexually harassed in service. In addition, she had a friend at home who was shot and had lost her job. The harassment in service continued even after she made complaints. Specifically, the veteran related that her supervisor forced her to touch him after he unzipped his pants. She stated that her nervous condition started due to sexual harassment that happened both on reserve duty and active duty. She sought treatment before she left the military. The records from 1986 were from when she still engaged in game-playing. In a written statement received in August 1992, the veteran explained that she was activated from reserve duty in January 1991. She endured sexual harassment even before she went on active duty. The sexual harassment consisted of sexual overtures and talk made around her. She also suffered distress from other issues, i.e., losing her civilian job, her mother losing her sight, her husband having heart problems, and a friend being killed. The RO received several statements from Daniel L. Schultz, Ph.D., a clinical psychologist. In the August 1992 statement, Dr. Schultz related that the veteran had been a patient for five years. When in the military, she functioned quite adequately. However, she experienced stress due to the circumstances surrounding her discharge and sexual harassment. In the May 1995 statement, Dr. Schultz explained that he began seeing the veteran in the fall of 1985 and continued to see her sporadically through last year, which included her time in the military. At different times, the veteran presented with different diagnoses. When he initially saw her, Dr. Schultz thought she displayed some schizophrenic characteristics. By her report, she had been hospitalized for a year and had seen a variety of psychiatrists. She was often suicidal and was committed to the Porter-Starke Mental Health Center when he saw her. Dr. Schultz stated that, throughout his involvement with the veteran, it was very clear that she could be extremely manipulative, could present herself as deeply disturbed or totally normal, and had some tendencies towards significant grandiosity. Finally, in an April 1998 statement, Dr. Schultz stated that he had not seen the veteran for several years. When he saw the veteran, she had no Axis I clinical diagnosis. He stated that all of her problems had been resolved prior to her involvement in the military. At the time the veteran enlisted, she had no symptoms of PTSD and no propensity to develop the disorder. According to VA outpatient medical records, the veteran presented in November 1994 with various symptoms and memories of how she was nearly raped two years before. The impression was PTSD. She returned about three weeks later in November 1994. In addition to the history previously provided, she indicated that she was divorced from an alcoholic husband. Examination was unchanged. The assessment was major depression without suicide ideation or risk and questionable PTSD. One week later in November 1994, the veteran asserted that she had been harassed in service and persecuted for turning in people for drugs in her reserve unit. She was currently pursuing a claim for service connection for PTSD from being almost raped. She explained that the psychiatric problems in her youth were faked to get away from home at age 16. Notes dated in December 1994 related that the veteran wanted to know how she could know she had PTSD. She was very angry with people who used and abused her in service. She also related that she was a victim of spousal abuse. The doctor stated that he would not tell her the symptoms for PTSD and noted that the fact that she used to feign illness raised the question of whether she would do it again. The doctor observed that the veteran was obsessed with revenge but did not have much evidence of PTSD. The RO obtained records from Dusan Gojkovich, M.D., relevant to a disability insurance evaluation. The initial evaluation in November 1994 indicated that the veteran manifested stress and a PTSD-type reaction related to an attempted rape. She did not admit to any previous psychiatric history. In a November 1994 statement, the veteran related that she noticed the stress problems in the second week of October due to numerous stressors, i.e., custody of her child. A document dated later in November 1994 showed the diagnosis of dysthymic disorder, acute anxiety, and PTSD, offered after the first two visits. The veteran was afforded a VA psychiatric examination in March 1997. She denied any history of inpatient psychiatric treatment or suicide attempts, but admitted to outpatient treatment for PTSD and dysthymia, as well as outpatient psychiatric help with her family at age 16. The veteran related that she was almost raped in February 1991 during active duty. Her supervisor pushed her on a bed, pulled down his pants, and made her touch him. He wanted her to perform oral sex on him. She stabbed him in the eye and he left her alone. He told her not to tell anyone and threatened her. However, there was an investigation. The veteran reported various subjective symptoms. The diagnosis was PTSD and atypical depression. The examiner commented that the atypical desperation was not related to the PTSD. In June 1997, the veteran underwent psychological evaluation and testing. She had a tumultuous relationship with her first husband, whom she met on a psychiatric ward. Her second husband was an alcoholic. She ended that marriage because of physical and alcohol abuse and depression. The veteran stated that her father had suffered from PTSD from being in a concentration camp in World War II. He was an alcoholic and physically abused his wife and children. In childhood, the veteran ran away from home and dropped out of school. At age 16, the veteran was hypnotized and allegedly sexually molested by her therapist. She thereafter had repeated psychiatric hospitalizations and had received outpatient treatment from several providers. Prior diagnoses included chronic residual undifferentiated schizophrenia, paranoid schizophrenia, schizoaffective disorder, borderline personality, major depression with suicidal ideation, dysthymic disorder, PTSD, anxiety disorder, and antisocial personality disorder. In service, the veteran was allegedly harassed, molested, and raped by an enlisted man. She refused to participate despite threats to her. Since the alleged rape, the harassment by Army personnel continued. She stated that her dog was killed in 1993. The examiner offered findings based on observations and testing results. He commented that, despite her numerous physical and psychiatric problems, the veteran was able to function in the work world before and during her military service. However, the alleged sexual assault precipitated her current recurrent panic attacks, headaches, nightly insomnia, paranoia, and obsessive ruminations that people are trying to harm her. The diagnosis was partner and parent child relation problem (past); physical abuse of child (father); physical abuse of partner (second husband); PTSD; generalized anxiety disorder; panic disorder; bereavement (father). The examiner also provided and Axis II diagnosis of antisocial personality disorder. In a December 1997 addendum, the examiner commented that the prior examination listed symptoms of PTSD, anxiety, and panic disorders. He stated that the veteran did not suffer from these symptoms prior to her military service. The symptoms of bereavement and dealing with abuse resolved prior to enlistment. After the alleged rape, the veteran had difficulty coping and working. Her symptoms were heightened by the alleged ongoing harassment. The veteran's service representative offered a personal statement in September 1997. He first met the veteran in March 1991 while she was still on active duty and he was the Executive Director of the Midwest Committee for Military Counseling. She had just been told that she would be given an other than honorable discharge. Throughout the first months of advising her, it was obvious from her behavior that she had experienced some traumatic event. When she told him about the sexual assaults, the reason for her behavior became apparent. Together they asked the Army Inspector General to investigate. In October 1997, the RO received a copy of the May 1993 report of Army's investigation of the veteran's complaints against four individuals. She alleged that, on one occasion between 1989 and 1991, a Sergeant McG. touched her outer uniform during formation and made a sexual comment to her. Although the specific conduct was not established, it was determined that he on occasion made comments that were offensive to female unit members. The veteran alleged that, between 1989 and 1991, a Sergeant S. made sexual comments and gestures to her. Investigation failed to demonstrate the specific conduct toward the vetera, but established that he made similar comments and gestures to other females and established misconduct and pattern of sexual harassment. The veteran alleged that, between 1989 and 1991, a Sergeant C. made sexual comments to her. Again, although the specific conduct was not established, it was determined that he made similar comments to other female unit members. Finally, the veteran alleged that a Sergeant J. exposed himself to her on or about 1990. Although this conduct was not established, investigation revealed that he did make sexual comments to other female members. The veteran underwent a VA psychiatric examination in December 1997. She related that her father was domineering but was never physically abusive to her or her mother. She was divorced from her physically and verbally abusive husband in 1992. In February or March 1991, the veteran's supervisor, a Sergeant J., took her to a building, jerked her shirt out, pulled down his pants, made her touch his penis, and pushed her head down. She fought him off. He told her that she would be discharged is she would not comply and that the Army would destroy her life if she told anyone. Since the incident, she felt that she was being followed. People from the military called her, helicopters hovered over her home, and members of her reserve unit shot her dog in 1991 and made threats against her family. The report revealed numerous subjective complaints and findings on examination. The diagnosis was depressive disorder and PTSD. Also in December 1997, the veteran underwent a psychological evaluation and testing. The diagnosis was dysthymic disorder and PTSD. The examiner commented that the veteran acknowledged many symptomatic manifestations of PTSD. However, the examples cited encompassed the whole spectrum of her experiences in the military in a rather loose manner, making it difficult to establish causal relationships to symptoms. The RO received two lay statements in November 1998. C.D.B. stated that she had known the veteran since 1990 when she was in the reserves. The veteran told her that the reserve unit she was with was annoying because the men would not leave her alone. When she came back from active duty in May 1991, she was not the same. She would speak and then burst out crying. The veteran admitted that she was physically and sexually assaulted. Her supervisor pulled off her clothes and tried to force her to perform oral sex. He threatened to kill members of her family if she ever told anyone. C.D.B. stated that she had witnessed the veteran being harassed after she started talking about it. She got obscene phone calls from, the veteran said, Army people. P.V. related that she met the veteran in the late summer or early fall of 1990. They wrote frequently from December 1990 to May 1991. After her discharge, the veteran had a definite personality change. At P.V.'s house, the veteran burst into tears and told her about suffering an attempted rape, threats against her life and her family, killing her dog, threatening phone calls, and being followed. P.V. stated that the veteran continued to endure threats by Army personnel, helicopters following her and watching her, threats against her family, military people running her off the road. In a January 1999 statement, a VA physician indicated that, according to the history provided by the veteran, her symptoms had persisted for years. It was his opinion that her present symptoms more than likely were not due to simple harassment. The veteran submitted a statement from J.A.D. dated in February 1999. He recalled that between January and June 1991, the veteran had problems with a Sergeant J., who constantly made passes at her and sexual threats. He overheard conversations in which the sergeant made sexual comments about her to others. He also overheard another soldier making some sexual comments about the veteran. One night when the veteran came home from work, she was a mess, upset, and did not want to talk about it. The next day, J.A.D. overheard the sergeant brag about having a "wild time" with the veteran and trying oral sex. In a May 1999 statement, J.A.D. stated that he heard Sergeant J. brag to another soldier about an attempted rape. He told the soldier that he had to rip her clothes off and drag her around the room by her hair until he got her on the bunk bed. He also told the soldier that he had to slap her a few times to keep her from screaming. The soldier he was talking to said he was going to try to force her to have sex with him. Private medical records showed that the veteran's husband was hospitalized in February 1991 for cardiac problems. Records regarding the veteran's mother reflected treatment dating to 1992. In addition, the RO received a crime report dated in December 1990 in which an individual was shot and killed. Correspondence from the veteran related that Beatty Memorial Hospital was closed in the 1970s. In response to a request for records of psychiatric treatment, St. Catherine's Hospital indicated that a search revealed no records for the date indicated. In response to a similar request, Saint Margaret Mercy Healthcare Centers related that it kept medical records for only 10 years and the veteran was hospitalized more than 10 years ago. Analysis Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated during active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred in line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). ACDUTRA is, inter alia, full-time duty in the Armed Forces performed by Reserves for training purposes or by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). INACDUTRA means, inter alia, duty other than full-time duty prescribed for Reserves or the National Guard of any state. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). 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 (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). A preexisting injury or disease is considered aggravated by military service where there is an increase in disability during service, absent a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). The presumption of aggravation may be rebutted only by clear and unmistakable evidence. 38 C.F.R. § 3.306(b). Service connection for PTSD in particular requires: 1) medical evidence establishing a clear diagnosis of the condition; 2) credible supporting evidence that the claimed in-service stressor actually occurred; and 3) a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 140 (1997); Zarycki v. Brown, 6 Vet. App. 91, 97 (1993). See 64 Fed. Reg. 32,807-32,808 (1999) (effective March 7, 1997) (to be codified at 38 C.F.R. pt. 3) (amending 38 C.F.R. § 3.304 to implement changes regarding combat veterans as set forth in Cohen v. Brown). With respect to the diagnosis criterion, the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter "the Court") has indicated that a "clear" diagnosis of PTSD is, at minimum, "an unequivocal one." Cohen, 10 Vet. App. at 139. The Court also acknowledged that VA's adoption of the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) effected a shift in diagnostic criteria from an objective standard to a subjective standard. See 61 Fed. Reg. 52695-52702 (1996) (amending 38 C.F.R. §§ 4.125 & 4.126). See also Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991) (where the law or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary). Thus, the sufficiency of a stressor to cause PTSD is a clinical determination for the examining mental health professional. Cohen, 10 Vet. App. at 153 (Nebeker, Chief Judge, concurring by way of synopsis). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy." See Gaines v. West, 11 Vet. App. 353 (1998) (Board must make a specific finding as to whether the veteran engaged in combat). If the claimed stressor is not combat related, the veteran's lay testimony, by itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain credible supporting evidence from any source that corroborates the veteran's testimony or statements. YR v. West, 11 Vet. App. 393, 397 (1998); Cohen, 10 Vet. App. at 147. In the particular case of claimed personal assault, VA has established special procedures for evidentiary development. See VA Adjudication Procedure Manual M21-1 (hereinafter Manual M21-1), Part III, paragraph 5.14c (Feb. 20, 1996) (substantially enlarging on the former Manual M21-1, Part III, paragraph 7.47c(2) (Oct. 11, 1995)). These procedures take into account the difficulty establishing the occurrence of the stressor through standard evidence and the need for development of alternate sources of evidence. The provisions of M21-1 dealing with PTSD are substantive rules that are the equivalent of VA regulations; VA is therefore required to follow these provisions. Patton v. West, 12 Vet. App. 272, 277 (1999); YR, 11 Vet. App. at 398-99; Cohen, 10 Vet. App. at 139. The final requirement of 38 C.F.R. § 3.304(f) is medical evidence of a nexus between the claimed in-service stressor and the current disability. In cases of claimed personal assault, VA recognizes that some evidence may require interpretation by a clinician to establish a relationship to the diagnosis. Manual M21-1, Part III, paragraph 5.14c(9). Accordingly, the general rule that post-service medical nexus evidence cannot be used to establish the occurrence of the stressor is not operative in such cases. Patton, 12 Vet. App. at 280. See Cohen, 10 Vet. App. at 145; Moreau, 9 Vet. App. at 396. As a preliminary matter, the Board observes that the veteran claims to have been sexually harassed throughout her enlistment in the Army Reserves. As indicated above, service connection may be established only for injuries incurred during INACDUTRA. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). Therefore, to the extent the veteran may allege entitlement to service connection for some psychiatric disorder stemming from INACDUTRA, the Board finds that there is no legal entitlement to such a claim. Moreover, although VA recognizes personal assault as a basis for a PTSD claim, sexual harassment is not so accepted. See Manual M21-1, Part VI, paragraph 11.38. The Board will first address the issue of a preexisting psychiatric disorder. Although the enlistment examination notes no psychiatric abnormality, the record is significant for a pre-service history of psychiatric treatment. The Board acknowledges that the veteran testified that she faked her earlier psychiatric problems to get attention. However, the Board finds the testimony unpersuasive. The claims folder contains records from Porter-Starke Services showing psychiatric treatment several years before her enlistment. Service medical records reflect her own report of a history of psychiatric treatment. During various VA psychiatric examinations, the veteran freely and in great detail described a history of psychiatric hospitalizations and treatment. Considering the whole of the evidence, the Board finds that there is clear and unmistakable evidence that a psychiatric disorder existed prior to service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Thus, service connection may be established on the basis of aggravation only. The issue then is whether the preexisting disorder underwent an increase in severity in service. Temporary or intermittent flare-ups of symptoms during service are not sufficient to be considered aggravation absent worsening of the underlying disorder. Jensen v. Brown, 19 F.3d 1413, 1416 (Fed. Cir. 1994); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Considering the evidence of record, the Board finds that the preponderance of the evidence is against a finding that a preexisting psychiatric disorder was aggravated during service. The pre-service medical records show diagnoses of chronic residual undifferentiated schizophrenia and dysthymic disorder. The service medical records show only complaints of severe anxiety and confusion. The March 1991 consultation from Dr. Brognog indicates that the veteran had reported a recent period of high anxiety and depression due to health problems of her husband and her mother and to losing her job. She was also very concerned about being discharged. Dr. Brognog opined that the veteran was not suffering from any severe clinical psychological syndrome. Thus, it appears from Dr. Brognog's opinion that the anxiety and depression shown at the time were not representative of an increase in any underlying psychiatric disorder, but were temporary reactions to stressful situations. In addition, the June 1991 VA examination was negative for any findings on mental status examination. Accordingly, the Board finds that there was no increase in any preexisting psychiatric disorder during active military service. The preponderance of the evidence is therefore against entitlement to service connection for a psychiatric disorder. 38 U.S.C.A. §§ 1110, 1111, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306(a). With respect to the specific claim for PTSD, the Board initially finds that, although the veteran's claim was initially adjudicated before either version of the Manual M21-1 provisions regarding PTSD from personal assault was in effect, it is satisfied that the development accomplished by the RO essentially fulfills the current requirements. The claims folder contains evidence including service records, statements from friends, and statements from prior psychologists. The veteran and her representative have very thoroughly pursued her claim. The Board finds no substantive reason to remand the claim for additional development and further delay final adjudication of the veteran's claim. The Board observes that the veteran is diagnosed as having PTSD and medical evidence relates the diagnosis to trauma experienced in service. The remaining issue is whether there is credible supporting evidence that the claimed in-service stressor actually occurred. The veteran asserts that she was sexually assaulted while on active duty in February or March 1991. As discussed above, when the stressor is not related to combat, the veteran's assertions alone are insufficient to establish the occurrence of the alleged stressor; the record must contain credible supporting evidence that corroborates the veteran's testimony or statements. YR, 11 Vet. App. at 397; Cohen, 10 Vet. App. at 147. Balancing and weighing the credibility of the evidence of record, the Board finds that the preponderance of the evidence is against entitlement to service connection for PTSD because the record lacks credible supporting evidence that the claimed stressors actually occurred. The Board finds that the single most important piece of evidence in this case is the May 1993 Army investigation report. The report lists specific allegations made by the veteran against named individuals. Generally, the veteran alleged several incidents of sexual comments and gestures. She also claimed that a Sergeant J. exposed himself to her. The report is negative for allegations of sexual assault as later described. In addition, the service medical records are negative for mention of any assault, requests for new treatment, indications of complaints without specific diagnosis or ailment, or any changes in behavior. The March 1991 statement from Dr. Brognog is silent as to report of sexual assault or evidence of behavior or personality changes commonly associated with sexual assault. Similarly, the August 1992 statement from Dr. Schultz refers to sexual harassment, but is negative for mention of sexual assault or associated behavior or personality changes. In fact, the first discernable date on which the veteran reported an attempted rape to a medical or mental health professional is November 1994, as shown by both VA outpatient records and records from Dr. Gojkovich, well after the alleged incident and the completion of the Army investigation. The record contains personal statements from C.D.B. and P.V., who each claimed to have known the veteran since 1990, from J.A.D., who apparently served on active duty with the veteran, and the veteran's service representative. Manual M21-1 indicates that testimonial evidence from confidantes such as family members, roommates, fellow service members, or clergy, are alternate sources of evidence to establish the occurrence of the stressor. C.D.B. and P.V. stated that the veteran told them about a sexual assault. Clearly, the credibility of such information is predicated on the credibility of the veteran herself. The Board finds that the veteran's credibility is questionable based her variable reports of personal facts and history and an apparent pattern of concealing her pre-service history of psychiatric treatment. In his initial statement, J.A.D. generally discussed the veteran's problems with sexual harassment in service and the overheard comments from Sergeant J. J.A.D. offered a subsequent statement after the veteran's claim was again denied and she, in his words, advised him to clarify his statement. At that time, J.A.D. stated that Sergeant J. admitted to ripping off the veteran's clothes, dragging her by the hair, and slapping her. The credibility of this statement is suspect in light of its timing and the other evidence of record, particularly the May 1993 investigation report. The September 1997 statement from the veteran's service representative indicates that they requested an investigation after the veteran told him about the sexual assault. However, as discussed above, the investigation report of record contains no allegation of sexual assault. In the December 1997 addendum, a VA examiner indicated that the veteran did not suffer from any of her current symptoms prior to her enlistment. As there is no evidence that this particular examiner had any contact with the veteran prior to his June 1997 examination, many years after her enlistment and separation from service, the Board considers this opinion not particularly probative. The January 1999 statement from a VA physician relates his opinion that her present symptoms were more than likely not due to simple harassment. The Board does not in this decision find that the veteran was not at some time subjected to some form of trauma. Indeed, the veteran herself has related that she was the victim of child and spousal abuse, although some of her statements are contradictory. In this decision, the Board only states that the record lacks credible evidence to corroborate the veteran's assertions of sexual assault in service, as is required by law and regulation. Despite the sympathies the Board has to the veteran's claim and her particular circumstances, action by the Board and VA is bound by the applicable law and regulations as written. 38 U.S.C.A. § 7104(c). In summary, the Board concludes that the evidence concerning the occurrence of the claimed sexual assault in service is not so evenly balanced as to require resolution of doubt in the veteran's favor. Accordingly, the Board finds that the preponderance of the evidence is against entitlement to service connection for PTSD. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304(f); 64 Fed. Reg. 32,807- 32,808; Manual M21-1, Part III, paragraph 5.14c. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is denied. REMAND In December 1994, the RO remanded the issues of entitlement to service connection for a sinus disorder and a back disorder for additional development and readjudication of each claim. The issues of service connection for a left hip disorder and a left leg disorder were deferred pending completion of the remand. A review of the claims folder reveals that the RO obtained or attempted to obtain the evidence as instructed in the remand. However, the claims folder contains no rating action or supplemental statement of the case in which the RO readjudicated the sinus and back claims as instructed. A deferred rating decision dated in August 1998 suggests that the RO was aware that additional action was required for these issues. However, the VA Form 8, Certification of Appeal, lists the additional issues, but they are crossed out. The undersigned is unable to locate any communication in the claims folder showing that the veteran chose to withdraw her appeal with respect to those issues. A remand is required to complete the action instructed in the previous remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is REMANDED to the RO for the following action: The RO should contact the veteran in writing and inquire as to whether she wished to withdraw her appeal with respect to the issues of service connection for a sinus disorder, a back disorder, a left hip disorder, and a left leg disorder. No further action is required for any issue or issues for which the veteran withdraws the appeal. If the veteran does not wish to withdraw the appeal of entitlement to service connection for a sinus disorder or a back disorder, the RO should readjudicate those claims based on all the evidence of record. If the disposition of any claim remains unfavorable to the veteran, the RO should furnish the veteran and her representative a supplemental statement of the case and afford the applicable opportunity to respond. Thereafter, the case should be returned to the Board for final appellate review, if in order. The Board intimates no opinion as to the ultimate outcome of the veteran's claims. She is free to submit additional evidence as desired. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. RENÉE M. PELLETIER Member, Board of Veterans' Appeals