BVA9506230 DOCKET NO. 93-11 040 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for a psychiatric disorder. 2. Entitlement to service connection for hearing loss. REPRESENTATION Appellant represented by: Thomas G. Reidel, attorney ATTORNEY FOR THE BOARD Thomas H. Tousley, Associate Counsel INTRODUCTION The veteran had active military service from March 1978 to March 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 1992 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. REMAND The veteran's service medical records show that during service he was enrolled in a treatment program for alcohol abuse during 1979. Approximately five months after his first completion of the program, it was noted that he was seen in July 1980 at the Community Mental Health Clinic of his installation hospital for problems related to work. One week later he was prescribed antidepressant medication. Shortly thereafter, he was enrolled again in the alcohol abuse treatment program. It appears that the veteran submitted the majority of records in this case. In May 1991, an Administrative Law Judge (ALJ) determined that the veteran was disabled for the purpose of receiving Social Security disability benefits. The veteran became eligible for such benefits in April 1982 when he last worked. The veteran's treating psychiatrist, Brendan T. Carroll, M.D., testified at a hearing before the ALJ in 1991 that the veteran currently had a bipolar disorder manifested by periods of mania followed by periods of severe depression. The treating psychiatrist opined that the veteran's current level of functioning was typical of his functioning since April 1982. The ALJ found that the veteran had experienced a disabling mental impairment since April 1982. The medical evidence of record shows that the veteran has been hospitalized on several occasions since 1982 for psychiatric treatment and for alcohol rehabilitation. The veteran has reported on several occasions that he has experienced periods of depression all of his life. He reported to a VA examining psychiatrist in April 1992 that he drank alcohol during service to feel better. Based on the above described evidence, the Board determines that the veteran has submitted a well-grounded claim for entitlement to service connection for a psychiatric disorder. Once the veteran has submitted a well-grounded claim, the VA has a duty to assist him in the development of his claim. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). The medical records provide conflicting evidence as to whether the veteran had an acquired psychiatric disorder that was either incurred in or aggravated by active military service. In May 1982, Roland E. Erikson, M.D., examined the veteran and diagnosed passive-aggressive personality disorder. This diagnosis was rendered following the veteran's arrest for destruction of property in his apartment and his previous arrest for driving while intoxicated. Around this time, the veteran was hospitalized at Mercy Hospital in Davenport, Iowa, but the records of this hospitalization are not before the Board. The veteran was hospitalized by the VA from August to October 1982. The psychiatric diagnoses on discharge were alcohol dependence and marijuana abuse. He was hospitalized by the VA from November 1982 to December 1982. Although some clinical records of this hospitalization are before the Board, the hospitalization report is missing. The pertinent diagnostic assessment on admission for Axis I was alcohol dependence, and rule out dysthymic disorder, and for Axis II, rule out antisocial personality disorder. In addition, a psychiatrist's note during the hospitalization indicates the veteran had exhibited anti- social conduct since childhood. Other medical records also note the veteran's antisocial behavior prior to service. During the hospitalization, a VA counselor proposed as one of the treatment goals, counseling to assess the nature of the veteran's depression and lethargy in the past. The veteran was hospitalized at Mercy Hospital from May to June 1983 for treatment of alcoholism. A consulting psychiatrist diagnosed alcohol dependence, dysthymic disorder, and schizoid personality. The discharge summary indicates that psychological testing indicated the veteran had depression secondary to a schizoid personality disorder. The report of the results of the psychological testing is not before the Board. He was hospitalized at the same facility in July 1983 according to an admission summary, but a copy of the hospitalization report is not before the Board. According to the admission summary, the veteran's wife was concerned about a change in the veteran's personality manifested by depression, lack of energy, various fears, and hypersomnia. The diagnoses were major depression and schizoid personality. According to information the veteran reported to the Social Security Administration, he received psychiatric treatment from Dr. Erikson from 1983 to 1984. The treatment records are not before the Board. The veteran was hospitalized by the VA from October to December 1984. Part of the hospitalization report appears to be missing from the record. He reported a long-standing problem with depression which prevented him from eating. The results of psychological testing were interpreted to show a clinical profile of an individual with a diagnosis of pseudo-neurotic or chronic undifferentiated schizophrenia. The pertinent psychiatrist diagnosis was alcohol dependence. During a VA hospitalization from March to July 1987, the veteran reported that he had experienced depression as a child. An initial psychological assessment indicates the veteran described a type of behavior going back to childhood that was typically associated with character disorders. The psychologist opined that the evidence suggested the existence of depression and possible thought related difficulties (e.g. schizoid tendencies). The Axis I diagnoses on discharge were dysthymic disorder, superimposed, with recent major depressive episode, and alcohol dependence. The Axis II diagnoses were mixed passive-aggressive and schizoid personality traits. The veteran was hospitalized by the VA from March to April 1988. The Axis I diagnoses on discharge were bipolar disorder, alcohol dependence, nicotine dependence, and marijuana abuse. Psychological testing during his VA hospitalization from January to February 1990 suggested findings of a character disorder. The pertinent diagnosis on discharge was alcohol dependence, episodic. A history of a bipolar disorder was also noted. The veteran was also receiving VA psychiatric care between hospitalizations, but the majority of these records are not before the Board. Dr. Carroll, the veteran's treating psychiatrist, stated in a letter dated in June 1990 that he diagnosed bipolar affective disorder and alcohol abuse. Dr. Carroll noted that the veteran abused alcohol when he was psychiatrically ill as well as when he was otherwise psychiatrically well. Dr. Carroll's treatment records of the veteran are not before the Board. As previously mentioned, a VA psychiatrist examined the veteran in April 1992. The psychiatrist reviewed the veteran's medical records since 1989, but was not able to review the veteran's claims folder. The VA psychiatrist's Axis I diagnoses were bipolar affective disorder, current mixed picture; alcohol dependence, in full remission; and marijuana abuse, in remission. Based on this conflicting evidence, the Board is unable to determine the onset of the veteran's bipolar disorder, and the relationship of this disorder to the diagnosed alcohol dependence and personality disorders. In addition, as indicated, relevant medical records are not before the Board. The duty to assist includes the obtaining of such records. See Dyess v. Derwinski, 1 Vet.App. 448, 455 (1991). The duty to assist also includes the obtaining of a thorough and contemporaneous examination to remove any diagnostic doubt that considers the records of prior medical examinations and treatment. Green v. Derwinski, 1 Vet.App. 121, 123-124(1991). The Board finds the VA psychiatric examination to be inadequate for resolving the issue of service connection for a psychiatric disorder because the examiner was not able to review all the relevant medical records and did not offer an opinion as to the relationship of the diagnosed psychiatric disorders to service. In addition, the Board notes that "the threshold for normal hearing is from 0 to 20 db, and higher threshold levels indicate some degree of hearing loss." Hensley v. Brown, 5 Vet.App. 155, 157 (1993). The results of audiometric testing of the veteran's hearing upon entry into service show puretone thresholds greater than 20 for both ears at 3000, 4000, and 6000 Hertz., while the results of audiometric testing in April 1980 show puretone thresholds at all levels to be within normal limits. However, in August 1982, within 15 months after separation from service, VA audiological testing revealed a bilateral mild to profound sensorineural hearing loss. The veteran has reported that he was exposed to noise during service on the rifle range because he served as a unit armorer at a basic training installation. It was also noted in August 1982 that the veteran was exposed to noise after separation from service while working in a plant that reconditioned steel drums. The Board determines that the veteran has submitted a well- grounded claim for service connection for hearing loss. However, due to the conflicting evidence, the Board is unable to determine whether the veteran's current hearing loss is related to service. There has been offered no medical opinion as to whether the veteran's hearing loss began during service, or whether a preexisting hearing loss increased in severity during service. Therefore, a remand is required to obtain an audiological evaluation, an ear examination, and a medical opinion. Accordingly, this case is REMANDED to the RO for the following action: 1. The RO should request all treatment records pertaining to the veteran for the period from January 1979 to March 1981 from the Community Mental Health Clinic at U.S. General Leonard Wood Army Hospital, Ft. Leonard Wood, Missouri. If these records are no longer maintained at this facility, the RO should attempt to obtain the records from the National Personnel Records Center (NPRC). All records obtained should be associated with the claims folder. 2. After receiving the necessary authorization from the veteran, the RO should obtain all treatment records pertaining to the veteran from (1) Dr. David Wettach at the Muscatine Health Center in Muscatine, Iowa, (2) Dr. Roland E. Erikson in Davenport, Iowa, and (3) Dr. Brendan T. Carroll, Great River Mental Health Center, in Muscatine, Iowa. 3. After receiving the necessary authorization from the veteran, the RO should obtain from Mercy Hospital in Davenport, Iowa the following: (1) the report of the hospitalization of the veteran during the first-half of 1982, (2) the report of psychological testing of the veteran during the hospitalization from May to June 1983, and (3) the report of the hospitalization of the veteran in July 1983. 4. The RO should obtain all VA outpatient psychiatric treatment records pertaining to the veteran not already in the claims folder. Furthermore, the RO should obtain the report of the veteran's hospitalization from November to December 1982 and the missing pages from the report of his hospitalization from October to December 1984. 5. After the actions requested in the above indented paragraphs have been completed, the veteran should be afforded a comprehensive VA psychiatric examination to determine the existence of any current psychiatric disorders, and their relationship to service. The examination should be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations (1985). All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. The examiner is requested to review the veteran's claims folder prior to the examination, including the service medical records. The examiner is requested to use the multi-axial system to state all diagnoses and render the diagnoses in accordance with the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (3d ed. rev., 1987). Based on a review of the medical records, and the examination findings, the examiner is specifically requested to offer an opinion in response to the following questions: (1) Does the veteran currently have a bipolar affective disorder?; (2) If the veteran currently has a bipolar affective disorder, what is the probable time of onset of the disorder?; (3) If the veteran had a bipolar affective disorder prior to service, did the disorder increase in severity during service?; (4) Does the veteran currently have any other Axis I or Axis II psychiatric disorders?; (5) If so, what is the probable time of onset of the disorders?; (6) If any of the other Axis I psychiatric disorders existed prior to service, did they increase in severity during service; and (7) if any substance abuse disorders are diagnosed, what is the relationship between these disorders and the other psychiatric disorders? The examiner is also requested to state the underlying reasons for his or her opinion. The examination should be performed even if the RO is unable to obtain all the medical records requested by the Board. The claims folder must be made available to and reviewed by the examiner prior to the requested examination. 6. The veteran should be afforded a VA audiological evaluation to be followed by a VA ear examination by a physician to determine the current severity of the veteran's hearing loss and its relationship to service. They should be conducted in conformity with the VA Physician's Guide for Disability Evaluation Examinations (1985). All indicated tests and studies should be performed. The examining VA physician is requested to review the veteran's service medical records and the pertinent VA medical records in the claims folder prior to the examination. Based on the findings from the audiological evaluation and ear examination, and a review of the claims folder, the VA physician is requested to offer an opinion as to the probable date of onset of the veteran's current hearing loss, and if the hearing loss existed prior to service, whether it increased in severity during service. Therefore, the claims folder must be made available to the VA examining physician prior to the examination. 7. Once all the requested actions have been taken, the RO should evaluate the veteran's claim for service connection for a psychiatric disorder and for hearing loss in light of the additional evidence. If the RO makes a finding contradicting that of a physician or psychologist, the RO should fully explain the basis of its finding. If the veteran's claims remain denied, the veteran and his representative should be furnished a supplemental statement of the case, and they should be afforded the applicable period of time to respond before the record is returned to the Board for further review. The purpose of this REMAND is to assist the veteran in the development of his claims and the Board does not intimate any opinions as to the merits of this case, either favorable or unfavorable, at this time. No action is required of the veteran until he is notified. WARREN W. RICE, JR. Member, Board of Veterans' Appeals 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. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).