BVA9503179 DOCKET NO. 92-05 460 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for a psychiatric disability; and, if so, whether service connection is warranted for a psychiatric disability. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD Susan S. Toth, Associate Counsel INTRODUCTION The veteran had active service from February 1953 to February 1956 and from April to November 1956. By decision of April 1959, the Board of Veterans' Appeals (Board) denied the veteran's claim for entitlement to service connection for a psychiatric disorder. In September 1991, the veteran requested that his claim be reopened. This matter came before the Board on appeal from a January 1992 rating decision, whereby the Regional Office (RO) determined that new and material evidence had not been submitted and that the veteran's claim was not reopened. A hearing was held on August 18, 1992, in Washington, D.C., before I. S. Sherman, who is the member of the Board designated to render the final determination in this claim and who was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). In November 1992, the Board remanded the case to the RO for additional development of the evidence. Following that development, the Board referred this claim for an advisory opinion from an independent medical expert in psychiatry in May 1994. The veteran was notified of the opinion request by letter dated during that month. Following receipt of the opinion, the veteran's accredited representative was forwarded a copy of that opinion in December 1994 and provided with a 60-day period in which to respond. The representative replied immediately indicating that they had no further evidence or argument to submit and that they concurred in the independent medical expert's opinion. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that evidence recently submitted is new and material warranting reopening and allowance of his claim. He avers that a psychiatric disability, manifested by generalized anxiety, was incurred in service, and that the medical records show continuity of symptomatology from discharge until the present time. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that new and material evidence has been submitted to reopen the claim for service connection for a psychiatric disability; and that the totality of the evidence supports the award of service connection for a psychiatric disability, classified as generalized anxiety disorder. FINDINGS OF FACT 1. Attempts to obtain all relevant evidence necessary for an equitable disposition of the veteran's appeal have been made by the RO. 2. Service connection for a neuropsychiatric disorder was denied by the Board in April 1959. 3. Additional evidence submitted since April 1959 is not merely cumulative, is relevant to and probative of the issue on appeal and could possibly change the outcome of the previous denial. 4. The presently diagnosed generalized anxiety disorder commenced during service and has continued until the present time. CONCLUSIONS OF LAW 1. Evidence submitted since the April 1959 Board decision which denied service connection for a neuropsychiatric disorder is new and material; and the veteran's claim is reopened. 38 U.S.C.A. §§ 5108, 7104 (West 1991); 38 C.F.R. § 3.156(a) (1993). 2. A psychiatric disability, classified as generalized anxiety disorder, was incurred in service. 38 U.S.C.A. §§ 1110, 1111, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The evidence considered by the Board in its decision of April 1959 may be briefly summarized. Service medical records are associated with the claims folder for both periods of enlistment. In September 1955, the veteran was seen complaining of nervousness and vision trouble without headaches. The diagnosis was psychogenic condition deferred. In November 1955, the veteran was seen complaining of general nervousness. At reenlistment examination in April 1956, his psyche was normal. In July 1956, he reported going to a palmist. It was noted that he rebelled against going to the neuropsychiatric clinic. It was also noted that he could be dangerous if "this" continued. During the second enlistment, the veteran was diagnosed as having schizoid personality in September 1956. The veteran reported that he had been nervous for the past five months and could not eat or sleep. The veteran was afraid that his wife would poison him and felt that she had put an "evil spell" on him causing him to become impotent. The examiner indicated that the veteran was a primitive, superstitious, schizoid and unstable individual. Psychological testing showed evidence of a schizophrenic trend. At that time, the examiner did not consider him to be psychotic; however, further military duty might precipitate a psychotic reaction. In November of that year, the veteran received a general discharge for unsuitability based on his character and behavior disorders and disruptive reactions to acute or special stress. The RO originally denied service connection for a psychiatric disability in 1957. In April of that year, the veteran had filed a claim seeking service connection for nervousness which he believed commenced in June 1955, during his first enlistment. In May 1957, the veteran underwent a VA examination, whereupon the diagnosis was psychoneurosis, anxiety reaction, severe, chronic. The veteran reported that he was irritable and jumpy all the time and did not like to be around people. Mental status examination revealed that the veteran was coherent, sequential and logical, with a normal stream of thought. His mood was one of tense anxiety and moderate depression. Pursuant to rating decision of July 1957, the RO initially awarded a 10 percent evaluation for psychoneurosis, anxiety reaction. However, an administrative appeal was entered due to a dissenting opinion. The veteran underwent another VA examination in October 1957, whereupon the diagnosis provided was emotional instability reaction with habit spasm (stuttering) without psychosis. The veteran had reported that he was afraid to go to sleep in the dark and that he woke up frightened with palpitations and tremulousness. The Chief Medical Officer of the VA then provided his opinion in December 1957 that the veteran's correct diagnosis was schizoid personality, there was no indication of anxiety reaction during service and that the diagnosis of anxiety reaction provided was not justified on the basis of the psychiatric findings. In the subsequent rating decision of December 1957, the RO determined that schizoid personality was not a disability for which compensation could be awarded by the VA. Accordingly, the earlier rating was revised. In April 1959, the Board issued a decision whereby service connection for a neuropsychiatric disorder was denied as having clearly and unmistakably preexisted service and as not having been aggravated by service. When a claim is disallowed by the Board, it may not thereafter be reopened and allowed, and no claim based upon the same factual basis shall be considered. 38 U.S.C.A. § 7104(b). In order to reopen his claim, the veteran must present or secure new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). A two-step analysis must be performed when the veteran seeks to reopen a previously denied claim. Manio v. Derwinski, 1 Vet.App. 140, 145 (1991). First, it must be determined whether the evidence is new and material, and if it is, the case must be reopened and evaluated on the merits taking into consideration all the evidence, old and new. New evidence means more than evidence that was not previously of record. New evidence is not merely cumulative of evidence previously considered. Colvin v. Derwinski, 1 Vet.App. 171, 174 (1991). In order to be material, the new evidence must be relevant and probative of the disputed issue; and there must also be a reasonable possibility that the new evidence, when considered in conjunction with all the evidence of record, would change the outcome. Smith v. Derwinski, 1 Vet.App. 178 (1991). Thereafter, various medical records were received to support the veteran's assertions that a psychiatric disability was incurred in or aggravated by service. In January 1966, the veteran submitted a statement from J. N. Willis, M.D., who reported that he treated the veteran for a nervous stomach in June 1965. From August to September of 1974, the veteran was hospitalized by the VA for anxiety neurosis, with depression. He complained of pressure and unresolved problems at work. He appeared anxious and nervous. His wife reported that he was always quiet and that this episode was related to his work situation. The following year, the veteran was seen in September on an outpatient basis. It was noted that the veteran continued to experience nervousness, headaches and insomnia, with an exacerbation of the condition since June. The diagnosis was anxiety neurosis. The veteran was hospitalized by the VA again from April to July of 1976, with a diagnosis of anxiety neurosis with depressive features. During the latter part of the hospitalization, the diagnosis was subsequently changed to passive-dependent personality disorder. He was admitted due to insomnia, nervousness, depression and numerous phobic complaints. The veteran was noted to be nervous, with a bland affect and a fair memory for recent and remote events, although he was correctly oriented. His insight and judgment were impaired. Also of record is a VA hospital summary reflecting inpatient treatment from October 1976 to January 1977 for passive-dependent personality. Upon admission, the veteran complained of depression, anxiety, insomnia, migraines and multiple somatic complaints. He also reported having hand tremors and problems swallowing. He exhibited overwhelming anxiety, nervousness, restlessness, and complaints of difficulty sleeping. He was oriented in three spheres and memory was intact. Judgment, however, was impaired. It was also indicated that he exhibited a great deal of dependency on the hospital. Later in January, the veteran was again hospitalized for an acute anal fissure. Treatment for a psychiatric condition was not provided. VA outpatient treatment notes dated from January to March of 1977 mainly reflect treatment for physical complaints. In February, the veteran was seen in the mental health clinic for a follow-up on his nervous condition. No change in his condition was indicated. In October 1991, the veteran submitted a contemporaneous statement from Bruce C. Newsom, M.D., who indicated that he performed five different employment physicals on the veteran for Sears between December 1956 and June 1964. The veteran "was terminated five different times, supposedly because of a nervous condition." He provided his opinion that the veteran continued to suffer from anxiety syndrome. Also submitted was a statement from Luther J. Smith, II, M.D., which was also contemporaneously dated. He indicated that the veteran was treated during 1986 for depression. Upon examination in October 1991, the veteran remained depressed and anxious. He noted the documentation of nervousness in 1955, while the veteran was in the service. He also noted the VA hospital record of 1974 which contained a diagnosis of anxiety neurosis with depression. He indicated that with the veteran's present depressed condition and the documentation of nervousness dating back to the service, it was his opinion that the veteran suffered from psychoneurotic reaction with depression and anxiety, chronic which should be service connected. In August 1992, the veteran and his wife appeared and testified before this member of the Board at a hearing on appeal conducted in Washington, D.C. The veteran stated that his brother died during his first period of enlistment. That event precipitated his first visit to a psychiatrist after he was refused permission to attend the funeral. Following separation after the first enlistment, he was married. He reenlisted in April 1956. His commanding officer disliked him and burdened him with extra duties. This period of service is what caused his nervous break down and psychiatric disorder. He did not have a psychiatric condition prior to service. Following discharge, he commenced treatment for a psychiatric disorder in 1974. Prior to that time, he self-medicated with over-the-counter sleeping pills. He indicated that if there was a time period when he did not receive treatment, it was because he did not have sufficient funds to do so. He reported that symptomatology included anxiety and the desire to not be around people. The veteran's wife stated that when she married the veteran, he was a happy, outgoing person. Following his reenlistment, he was hostile, had trouble sleeping and was anxious. The veteran indicated that he felt stress due to his familial responsibilities of raising his children. He stated that he had an outgoing personality prior to service, had no trouble sleeping and did not have treatment for a psychiatric disorder prior to service. In November 1992, the Board remanded the case for additional development of the evidence. The RO was requested to contact various medical providers and the veteran's former employer who were the following: (1) Neal Willis, M.D.; (2) Bruce Newsom, M.D., (3) Luther Smith, M.D.; (4) Larry Brightwell, M.D. and; (5) Sears. Thereafter, the veteran was to undergo a VA examination to determine the proper diagnosis of his psychiatric disorder. The letters directed to Dr. Brightwell and Dr. Willis could not be delivered by the United States Postal Service, and thus, were returned to the RO. Medical records dated from August 1986 to March 1993 were received from Dr. Smith. The veteran was first seen in August 1986 complaining of pressure, depression, anxiety and insomnia. He described himself as a worrier. The diagnostic impression was depressive reaction. In April 1987, the veteran indicated that he was fearful during the evening hours. He was depressed. In October 1991, he continued the diagnosis of depressive reaction, chronic. In February 1993, the veteran was seen complaining of anxiety, depression and exhaustion. The previous diagnosis was confirmed and continued. In March 1993, reported symptoms included loss of energy, decreased sexual activity and depression. Dr. Smith also provided a statement dated during that month in which he indicated that it was his opinion that the veteran had a psychosis during service in 1955. He believed that the veteran's depression and occasional bizarre actions commenced in 1955 and continued until the present. The diagnosis reached was depression and anxiety, chronic which was related to service. Outpatient treatment notes were also received from Dr. Newsom that were dated from September to October 1991. This included the statement summarized above and a notation made in September 1991 that a consult was conducted with the veteran concerning his VA claim. A Sears' representative submitted a statement dated in May 1993 to the effect that any records pertaining to the veteran dated in 1956 would have been destroyed years ago. In June 1993, the veteran underwent a VA psychiatric examination. The veteran reported that he was anxious and was unable to sleep without medication. Mental status examination revealed that he was depressed, preoccupied in his own mind and had poor concentration. The diagnosis provided was major depression. In May 1994, the Board determined that the medical controversy involved in this case required the opinion of an independent medical expert. See 38 U.S.C.A. § 7109(a). Accordingly, a request was referred to an independent medical expert during that month in order that the following question might be answered, "What is the proper diagnosis of the veteran's psychiatric condition in service?" In June 1994, the veteran forwarded various records to the Board, which were copies of records previously associated with the record. The doctor provided his opinion in November 1994 as follows: The opinion requested in the board letter dated October 19, 1994 and signed by Charles W. Symanski was "What is the proper diagnosis of the Veteran's psychiatric condition in service?" It is my opinion that, using current DSM-IV criteria, the proper diagnosis for HP's condition in service is Generalized Anxiety Disorder (DSM-IV code 300.02). DISCUSSION OF FACTS AND MEDICAL PRINCIPLES INVOLVED IN DIAGNOSIS: The above diagnostic opinion is based on a detailed review of the documentation provided by the Department of Veterans Affairs concerning HAP. This documentation extends over a 41-year period beginning in February of 1953 and extending to the present. Documents reviewed include service medical records for the appellant's two periods of active duty, psychiatric evaluation dated May 9, 1957, signed by Thomas M. Hall, M.D., the V.A. examination signed by C.R.F. Beall, M.D., dated October 10, 1957, the records of the appellant's for multiple V.A. hospitalizations, visit records, letters, and reports from Dr. Barry Bratwell, Dr. Bruce Newson and Dr. Luther Smith, numerous letters, statements, and appeals by the appellant, hearing records and reports concerning appeals. As in any human endeavor, there are imperfections, omissions and some contradictions in this extensive and complex record. Nevertheless, with the advantage of the long historical perspective afforded by this extensive series of documents, I believe that it is possible to identify some of the major clinical issues involved and also to understand why the resolution of the appellant's claim has been so difficult. Having served as a military psychiatrist during the Vietnam War and having worked at several V.A. facilities in the past, I believe I can appreciate the challenges involved in these difficult situations and difficult times. The facts and medical principles involved in my retrospective diagnosis can best be grouped in several categories. OVERVIEW OF DIAGNOSTIC ISSUES: As I read through this extensive record I was struck by the preponderance of anxiety disorder symptoms in the appellant's clinical picture, especially early in his course. These are noted in his own chief complaints, in a number of examinations, and are reflected in the initial diagnoses he received. An exception is the crisis which occurred in July 1956 and which lead to the appellant's final separation from the service. I will discuss this event in detail later, but I believe that it distracts from and obscures rather than clarifies the actual diagnostic picture. Shortly after his separation from service the appellant began a long series of contacts with physicians, the Veterans Administration Medical System, and the Veterans Administration Disability Rating System. In his contact with physicians the clinical picture has remained predominantly that of an anxiety disorder with the gradual mixture of various depressive components. As part of the crisis which caused his separation from the service and at several points during official V.A. examinations, the diagnosis of a personality disorder has been given. I do not believe that the record justifies the initial diagnosis or the subsequent diagnoses of personality disorder. Over the years the appellant has had a number of episodes of psychiatric disorder which have significantly interfered with his occupational, social and family adjustment. Over the same prolonged period he has relentlessly pursued his claim for a service connected psychiatric disorder and this pursuit itself has had a significant effect on his life and on the way that he feels about himself. Over the past 41 years HP's problems refused to go away, HP refused to go away, and the Department of Veterans Affairs continues to struggle with the merits of his claim. I will now move to a more detailed consideration of the factors involved. RELEVANT MATERIAL IN EARLY RECORDS: Although it is fragmentary in nature, the early material from before July of 1956 provides the diagnostic information least contaminated by HP's subsequent struggles with the issue of his disability. The sick-call visit reports from his first enlistment refer to a number of "normal" illnesses but also feature three reports that suggest an anxiety disorder. On the 2nd of April, 1953, he complained of cold and chills right after his immunization. The impression was a needle reaction. This particular episode may have relatively little clinical significance. However, on the 20th of September, 1955 the appellant was seen by Dr. J. Struminsky who made the following entry: "Patient says he feels nervous and his vision are (sic) giving him trouble without any headaches. Temperature normal - says his knees give out." His diagnosis was psychogenic condition deferred. He was prescribed Donnatal and told to return the next day. On September 21, he was seen again complaining of nervousness and Dr. Struminsky noted "frequent sick call with psychogenic complaints, general nervousness and anxiety." He recommended consultation with a psychiatrist, but there is no documentation that this was ever followed through. On November 21, 1955, the appellant was again seen by Dr. Struminsky complaining of "nerves". Dr. Struminsky found "general nervousness" and prescribed phenobarbital, a long acting barbiturate which was the antianxiety medication commonly used during that period of time. These are the only directly relevant and "uncontaminated" records, but they clearly point to an anxiety disorder. In addition, the absence of any significant disciplinary problems and the several decorations awarded to the appellant would cast some doubt on the diagnosis of a clinically significant personality disorder. Though he may have been suffering from an anxiety disorder during his first enlistment, the appellant was able to carry on his military duties. Following his return home and inability to find work the appellant reenlisted. His reenlistment and discharge exams reveal no psychiatric abnormalities but this is not uncommon in these general exams on large numbers of asymptomatic individuals. 2ND ENLISTMENT AND EVENTS SURROUNDING SEPARATION FROM SERVICE: In attempting to understand the events that culminated in the appellant's separation from service, all that is available are the contemporary records and the appellant's often -repeated retelling of these events over the years as part of his many appeals. Interestingly, the events as described by the appellant do not seem to have changed very much. He reenlisted in the service because of his inability to find work at home, hoping to last until retirement and be able to "hold his head up in his community" as he stated in one of his later appeals. While in Ft. Benning, Georgia he was greeted by an unfriendly welcome born of an unfortunate coincidence of names. This incidence is referred to indirectly in early letters from the appellant (June 1961: "I could state a lot of things that happened at Ft. Benning, Georgia that would help my case, but I never did believe in trying to hurt people that do you wrong. I try to help those that wishes me harm.") Later the appellant told of the incident which involved another soldier with the same last name as his who had significant amounts of trouble in the service and whom the commanding officer "had just gotten out of jail". The appellant stated in his November 18, 1992 appearance before the Board of Veterans Appeals "I saluted him and he said every P I had ever seen is a no good S.O.B., I've just gotten one of you out of jail and I don't want you in my company. I said, Sir all I ask you for is a chance. I saluted him, did an about- face, went to the supply room and was issued my equipment." In this atmosphere of stressful insecurity, the appellant described an unrelenting work schedule leading to an all night stint driving a jeep to be followed by KP duty the next morning. In July of 1956, the crisis that lead to the appellant's separation of service occurred. He was referred to the N-P clinic with the following note "EM who thinks he's under evil spell. Has been going to palmist. Actually rebels against seeing you, but I feel that he could be dangerous if this continues. Please evaluate. " The note on this same consultation sheet dated the 27th of February, 1956 indicates that the appellant was given Nebutal to take at bedtime (a barbiturate used as a sleeping pill). The evaluation process that ensued lead to a report dated 11, September, 1956 signed by J.G. Margrett, Captain Medical Corps. For the first time, the diagnosis of a personality disorder occurs (Schizoid Personality). Despite the diagnosis, there is no documentation in this examination of the gradual manifestation of withdrawal from social relationships, indifference to the praise or criticism of others, and flattened emotional responsiveness which have characterized this personality disorder for the almost 40 years since this diagnosis was recorded on the appellant. Instead, it is described that he was "nervous for five months. Couldn't eat or sleep." At this point, the examiner describes an episode of decreased sexual function in the appellant and his worry that his wife has "put an evil spell on him and taken his nature away from him." The examiner then notes "he has gone to a fortune teller who agrees with his interpretation of the situation." Later in the description the appellant is described as "primitive, superstitious, schizoid, unstable individual." It is felt to be of great importance both for the welfare of the service and of the individual that he be administratively separated expeditiously as possible. Further duty runs a real risk of precipitating a psychotic reaction." In his findings, the examiner notes that "this condition is not amenable to hospitalization or treatment" and not be dealt through medical channels. The recommendation concludes "that no further attempt at rehabilitation of the soldier be made, since it is believed that he is useless to the service and such attempt would be of no avail." The events of the past almost 40 years, both with the appellant himself and in the growth and development of American Psychiatry, make it clear that this initial impression was probably mistaken. The current edition of DSM-IV, unlike any previous diagnostic and statistical manuals, has in Appendix I, (pages 843-849) an "Outline For Cultural Formulation and Glossary of Culture-Bound Syndromes". This addition reflects our growing understanding of a number of specific culture-bound syndromes that sometimes overlap with conventionally understood psychiatric disorders but that sometimes exists in individuals who, in their culture, are considered mentally healthy. One of the syndromes described is rootwork (pages 847- 848) "a set of culture interpretations that ascribe illness to hexing, witchcraft sorcery or the evil influence of another person. Symptoms may include generalized anxiety and gastrointestinal complaints... Rootwork is found in the southern United States among both African American And European American Populations, and Caribbean Societies." The sequence of a commanding officer unable to understand the appellant's feeling that he was under a spell, the officer's revulsion and disapproval at the practice of consulting a non-"professional" practitioner, and his incorrect consideration of it as clear evidence of being a "primitive, superstitious, schizoid unstable individual", was probably not unusual at the time. Far from being emotionless, however, the appellant was and continues to be troubled by anxiety symptoms. No significant paranoid trends or psychotic symptomatology have emerged over the course of many years. Instead, chronic and severe anxiety symptoms have become increasingly prominent. Whatever confidence the appellant had in the military was severely shaken, in addition, by his sense of betrayal that his commanding officer appeared with him ("I'll stand with you") at his hearing leading to his separation from service. The appellant felt, and may have been, betrayed by his action or by his own misunderstanding of it ("difficulty concentrating or mind going blank" is one of the current criteria for generalized anxiety disorder.) There is no clear evidence in the record that conventional sympathetic command counseling, with or without the psychiatric treatments (probably on an outpatient basis) that were available at that time would not have lead to a restitution of function in the appellant and allowed him to have completed his full military career. INITIAL PSYCHIATRIC EVALUATION FOLLOWING DISCHARGE: Soon after his discharge from the service, perhaps at the suggestion of his sergeant neighbor, the appellant sought evaluation for "nervousness" in an Application for Compensation dated April 11, 1957. The psychiatric evaluation dated May 9, 1957, signed by Thomas M. Hall, M.D. is in marked contrast to the separation from service examinations which have just been reviewed. The appellant presented an unremarkable past history and history of schooling, occupational, and social life up to the period of the reenlistment military service. At the time he was evaluated in May of 1957, less than a year after his discharge, his chief complaint was of "stiffness in neck, nervousness, sleeplessness, appetite is poor, and is losing weight at the present time. Feels irritable and jumpy all the time. Patient is stuttering all the time, which has gradually grown worse; there are times he states, when it relaxes, it is not with him, but it bothers him considerably. Patient does not like to be around people too much. States his main trouble is: that he is always in a hurry. States he cannot sit still or settle down." In his description of the present illness the examiner notes that the appellant felt he was "always on pins" at Ft. Benning, feeling "jumpy, and felt he would always have to toe the mark, that if he did not he would get into trouble - which he did in spite of everything. At that time he started having trouble sleeping, loss of appetite, etc." The mental status examination at that time showed a well developed male who appeared tense and nervous, the mood "of tense anxiety and moderate depression" and the diagnosis offered: "psychoneurosis, anxiety reaction, severe, chronic". This first V.A. exam specifically confirms the diagnosis of what would now be called generalized anxiety disorder. For the sake of completeness: criterion A of excessive anxiety and worry with a six month duration is met. Criterion B "The person finds it difficult to control the worry" is met. Criterion C: there are three items required in the current diagnostic system, and the appellant clearly met the criteria of "restless or feeling keyed up on edge," and "irritability," and "sleep disturbance." The exclusion criteria D and F are not met and criterion E is met: "The anxiety, worry or physical symptoms cause clinically significant distress or impairment, social, occupation or other important areas of functioning." It should be noted that even in this early examination a depressive component was identified. This has reappeared in many subsequent evaluations and could represent demoralization over the situation and his inability to get the help or compensation he felt he needed, or might represent a more essential component of the appellant's anxiety disorder. Interestingly, in the current DSM-IV, "mixed anxiety - depressive disorder, is described as one of the criteria sets provided for further study (page 723-725), reflecting the continued realization that anxiety and depressive symptoms are often mixed. Despite Dr. Hall's clearly documented, seemingly well reasoned report, a dissenting opinion was expressed and the diagnosis was returned to schizoid personality. It is unclear what, if any, objective basis existed for this change. With this perceived rejection, the appellant's long struggle with the V.A. system began. PSYCHIATRIC AND ADMINISTRATIVE EVENTS FROM 1957 TO PRESENT: The various evaluations, letters from the appellant, and sworn testimonies allow us to piece together a picture of the appellant's subsequent clinical course. As mentioned on page 13 of his 1982 hearing transcript he continued to function, but began using over-the-counter antianxiety medications ("nervene") to calm himself. In the same testimony, his wife indicated clearly that she had considered him, in their culture group at the time she met him, a stable normal person and a desirable mate, again contraindicating the usual picture of schizoid personality. A particularly revealing self description is probably best given on page 7: "Over the years it has gotten - I've gone from - I seem to be going more extreme. I was determined to make it regardless of whether - however I was discharged. If anything, I was just going to forget about the Army period. So, I went to work and I worked hard, but I was always taking some type of nerve medicine. I was going to different doctors." Whether it was an inpatient or an outpatient evaluation, whether is was done by the V.A. or by a private physician, the appellant's symptoms and course appeared most consistent with a chronic fluctuating anxiety disorder and, consistent with this impression he was treated psychopharmacologically mostly with antianxiety medications and with antidepressants (which are often used in anxiety disorders). Statements like "All his NP symptoms had always been the same" in the October 10, 1957 evaluation are clearly contradicted by his history. Similarly, the reasoning in the decision of April 21, 1959 that "the Veteran's NP disorder was not aggravated by service" does not seem to be supported by the documentation that is presented. The diagnosis of anxiety neurosis with depression was made during the hospitalization at the V.A. hospital, Tuskegee, Alabama in August to September of 1974 with the diagnosis of personality disorder (this time passive-dependent personality) reappearing in the April and October, 1976 hospitalizations. Review of the documentation, however, reveals that despite the personality disorder diagnosis the symptoms described were clearly in the anxiety disorder group: "I wake up sometimes at night. I am scared and run. I will be gasping for fresh air and my heart beats fast." In accordance with this, a diagnosis of anxiety neurosis with depressive features is presented by C.C. Allen, M.D. on 6/15/76, but in a pattern that was to repeat itself the diagnosis was changed to passive dependent personality in the final discharge summary signed by T.S. Ganesh, M.D. The hospitalization at the Veterans Administration Hospital in Tuskegee from 10/76 to 1/77 again featured complaints of anxiety, tension, mild depression, and insomnia, but the main diagnosis, rather than being an anxiety disorder, was passive dependent personality. What underlies these seemingly discordant and largely undocumented personality disorder diagnoses may be reflected in statements like "patient continued to be superficial, manipulative and displayed a great deal of dependency on the hospital." The complex causes of this type of hospital behavior are not analyzed at all, and no supporting data for the longitudinal diagnosis of a personality disorder is given in the history. Along with his stays at the Veterans Administration Hospitals the appellant was seen by various private physicians. None of these physicians made the diagnosis of a personality disorder of any type, or developed any information that would lead to such diagnosis by a reviewer. In fact, their diagnoses were remarkably consistent of an anxiety disorder with depressive features. Of particular importance, especially in comparison to letters and statements solicited in support of applications for disability, is the available record of the appellant's first office visit to Dr. Smith, who seems to be the physician who has treated him most regularly. This occurred on August 29, 1986 and showed complaints of depression and the appellant "describes himself as being a worrier." Significantly he stated that "the fact that he didn't get disability benefits when he came to see Dr. Foster was probably a blessing in disguise because he has been in his own auto repair business for some time now." This would contradict a pattern of dependency and pension seeking behavior and support the picture of a man who does his best to work and be independent despite his disorder. Later in the note his symptoms are described: "Primarily he has been unable to sleep, is very anxious and been very depressed." Dr. Smith's initial impression was depressive reaction, and he placed the appellant on a combination of antianxiety and antidepressant medication (Limbitrol). His first note lends some support to Dr. Smith's conclusion in his letter of October 10, 1991 that the appellant "does suffer with a service connected disability, the diagnosis being psychoneurotic reaction with depression and anxiety, chronic." The depressive component appears to have increased in recent years, so that in the June 14, 1983 compensation and pension exam report reviewed and signed by M. Del Castillo, M.D., the diagnosis is given as major depression. Although this reroute is extremely brief, and no clear documentation of the new diagnosis is given, no mention is made of a personality disorder diagnosis. SUMMARY AND CONCLUSION: The available information leads this reviewer to the conclusion that the proper diagnosis of this veteran's psychiatric condition in service was generalized anxiety disorder (DSM-IV 300.02). In the subsequent years since his discharge, his clinical course has confirmed this initial diagnosis, with the addition of increasingly prominent depressive features. His course has given no evidence of the typical course of a disabling personality disorder. The unfortunate crisis that ended this veteran's second enlistment may have been due to a cultural misunderstanding, leading to the application of a schizoid label where none was justified. Once applied, the label, like many examples of stigma, was difficult to get rid of and interfered with HP's efforts over the years to get treatment and to go on with his life. Psychiatry, the Army, and the Veterans Administration have changed a great deal since HP first enlisted, and the efforts of all those involved in his evaluation and care should be viewed with that understanding. I. Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for a psychiatric disability. The statement of Dr. Smith dated in October 1991 and the independent medical expert's opinion are new and material evidence. The panel considers this evidence new because it tends to show that an anxiety disorder commenced during service. In this regard, the Court has stated that for purposes of determining whether a claimant has submitted new and material evidence only, the credibility of the evidence is to be presumed. Once the evidence is found to be new and material and the claim is reopened, the presumption that it is credible and entitled to full weight no longer applies. Justus v. Principi, 3 Vet.App. 510, 513 (1992). In this case, presuming the credibility of the evidence, the outcome of the prior denial could be different, and therefore, the veteran's claim will be reopened and considered on the merits. II. Entitlement to service connection for a psychiatric disability. In this case, the Board must first decide with respect to reopening the claim whether the appellant will be prejudiced in any way by consideration of the reopened claim when the RO has not addressed that underlying issue. The factors to be considered include whether the claimant has been given adequate notice of the need to submit evidence or argument on the underlying claim, an opportunity to submit such evidence of argument, and an opportunity to address the issue at a hearing. Bernard v. Brown, 4 Vet.App. 384 (1993); VA O.G.C. Prec. Op. No. 16-92 (July 24, 1992). In the case at hand, the Board concludes that the appellant will not be prejudiced by its consideration of the underlying claim. The veteran has submitted numerous statements in which he set forth his arguments on the substantive issue. He also presented his arguments on the merit-based issue in the form of testimony at a hearing on appeal. In short, it appears that the veteran has been given the opportunity to argue the merits of the underlying claim and he has taken advantage of that opportunity. As recently as December 1994, the Board requested that the accredited representative present any additional evidence or argument to support the claim. An immediate reply in the negative was received. Accordingly, it does not appear that anything would be gained by further delay of the appellate process. Since prejudice to the appellant is not shown, appellate consideration will proceed. The veteran satisfied the threshold requirement of presenting a well-grounded claim for service connection within the meaning of 38 U.S.C.A. § 5107(a). That is, he set forth a claim which was plausible. The Board is also satisfied that all relevant evidence has been properly developed, and that no further assistance is required to comply with the VA's duty to assist as mandated by 38 U.S.C.A. § 5107(a). Under the current applicable criteria, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. A veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed in sound condition except for defects noted when examined and accepted for service. However, clear and unmistakable (obvious or manifest) evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. §§ 1111, 1137; 38 C.F.R. § 3.304(b). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Following review of all the evidence of record, the Board concludes that service connection is warranted for a psychiatric condition, manifested by generalized anxiety disorder. The record contains varying diagnoses of the veteran's psychiatric condition. Upon hospitalization by the VA in 1974, the diagnosis was anxiety neurosis, with depression. That diagnosis was continued in a VA outpatient treatment note of September 1975. During a VA hospitalization in 1976, the initial diagnosis of anxiety neurosis with depressive features was subsequently changed to a personality disorder. That diagnosis was continued upon subsequent VA hospitalization from October 1976 to January 1977. In October 1991, Dr. Newsom indicated that the veteran suffered from anxiety syndrome; and Dr. Smith provided a diagnosis of psychoneurotic reaction with depression and anxiety. Finally, in June 1993, a VA examiner provided a diagnosis of major depression. In an effort to ascertain the true psychiatric disorder exhibited by the veteran, the Board requested an opinion from a medical expert. The expert based his opinion that the veteran suffered from generalized anxiety disorder on the entire evidence of record and the current diagnostic criteria for mental disorders. He also reviewed all diagnoses of record and clearly and concisely reconciled the conflicting diagnoses based on the symptomatology presented by the veteran at the time those diagnoses were provided. He provided his opinion that the sole psychiatric disorder exhibited by the veteran based on the recorded symptomatology was generalized anxiety disorder. The Board finds this opinion highly probative due to the doctor's comprehensive review of the record, his reconciliation of conflicting medical diagnoses, and his expertise in the field of psychiatry (the independent medical expert is an Associate Professor of Clinical Psychiatry at The Ohio State University Medical Center). See Gabrielson v. Brown, 7 Vet.App. 36 (1994); Guerrieri v. Brown, 4 Vet.App. 467, 470-71 (1993). Moreover, the opinion provided confirms the diagnosis and opinion provided by Dr. Smith, who opined in October 1991 that the veteran had psychoneurotic reaction with depression and anxiety which dated back to service. Subsequently in March 1993, Dr. Smith indicated that following further review of the veteran's records, it appeared that the veteran had depression and anxiety in 1955 which continued until the present. This medical opinion is also entitled to some probative value. However, the probative value is somewhat diminished since the doctor appears to have reviewed only those past medical records which contained diagnoses of anxiety. Accordingly, he was unable to base his diagnosis upon the entire medical history or reconcile the previous conflicting diagnoses. Based on this new and material evidence, the Board finds that the presumption of soundness is no longer clearly and unmistakably rebutted as it was in the decision of April 1959. The independent expert medical opinion indicates that generalized anxiety disorder did not preexist service, but rather commenced during service. In 1959, the Board found that a neuropsychiatric condition preexisted service based on the veteran coming from a broken home, his leaving school in the 10th grade, his having stuttered his entire life and his having reported during the VA examination of October 1957 that the neuropsychiatric symptoms had always been the same. The independent medical expert, however, opined that the veteran's statement to the effect that his neuropsychiatric symptoms were always the same was contradicted by the reported history. Since the Board finds this opinion highly probative, the presumption of soundness applies and the veteran will be presumed to have been in sound condition when examined and accepted for service during the first period of enlistment. See 38 U.S.C.A. § 1111. The independent medical expert indicated that the veteran clearly had an anxiety disorder during the first period of active duty based on the service medical records. Moreover, although the diagnosis was not clearly established during service, the symptomatology present at that time (anxiety, nervousness and trouble sleeping) has continued, based on the medical records dated after discharge. Therefore, the evidence supports the veteran's claim that service connection for generalized anxiety disorder is warranted as having been incurred during his first period of active duty. ORDER New and material evidence has been presented to reopen the appellant's claim; and service connection for a psychiatric disability, classified as generalized anxiety disorder, is granted. I. S. SHERMAN Member, Board of Veterans' Appeals (Continued Next Page) The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.