Citation Nr: 0000136 Decision Date: 01/04/00 Archive Date: 12/28/01 DOCKET NO. 96-23 328A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for a bipolar disorder. 2. Entitlement to service connection for residuals of a coma. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Theresa M. Catino, Counsel INTRODUCTION The veteran served on active military duty from April 1977 to May 1981. This appeal arises from a July 1995 rating action of the Boston, Massachusetts, regional office (RO). In that decision, the RO denied service connection for residuals of a coma and a bipolar disorder. (Previously, in November 1984, the Board of Veterans' Appeals (Board) denied a claim of service connection for a personality disorder. The November 1984 decision of the Board and the rating decisions subsumed thereby did not specifically address the question of entitlement to service connection for a bipolar disorder. Consequently, the veteran's present claim for service connection will be adjudicated on a de novo basis.) In February 1998, the Board remanded the veteran's service connection claims to the RO so that a requested hearing could be scheduled. However, the veteran failed to report for the hearing. Consequently, the veteran's case was returned to the Board. FINDINGS OF FACT 1. The record contains no competent evidence associating any bipolar disorder that the veteran may have to his military service. 2. The veteran has been diagnosed with cognitive impairment which has been linked to his military service. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a bipolar disorder is not well grounded. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1999). 2. The claim of entitlement to service connection for residuals of a coma is well grounded. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The threshold question that must be resolved is whether the veteran has presented evidence that his claims are well grounded. See 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). A well-grounded claim is a plausible claim, one that appears to be meritorious. See Murphy, 1 Vet.App. at 81. An allegation that a disorder is service connected is not sufficient; the veteran must submit evidence in support of the claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993). Generally, in order for a claim of service connection to be well grounded, there must be proof of present disability. Brammer v. Derwinski, 3 Vet.App. 223 (1992); see also Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992) (requiring, for a well-grounded claim, competent evidence that a veteran currently has the claimed disability). There must also be evidence of incurrence or aggravation of a disease or injury in service. See Caluza v. Brown, 7 Vet.App. 498 (1995). The claimant must also submit medical evidence of a nexus between the in-service disease or injury and current disability. Id. Where the issue is factual in nature (e.g., whether an incident or injury occurred in service), competent lay testimony, including the veteran's testimony, may constitute sufficient evidence to establish a well-grounded claim; however, if the determinative issue is one of medical etiology or a medical diagnosis, competent medical evidence must be submitted to make the claim well grounded. See Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). However, where the issue does not require medical expertise, lay testimony may be sufficient. See Layno v. Brown, 6 Vet.App. 465, 469 (1994). Bipolar Disorder Throughout the current appeal, the veteran has essentially asserted that service connection is warranted for a bipolar disorder. Specifically, in a March 1996 statement, the veteran maintained that, following a head injury, he became depressed and was actually treated for depression during his active military duty and since that time. According to the veteran's service medical records, an undated report notes that one of the veteran's problems was a psychopathic personality disorder defined in 1972. Additional reports indicate that, in August 1979, the veteran underwent a private psychiatric evaluation at which time the examining psychiatrist provided the impression of acute and chronic alcoholism as well as emotionally immature and psychopathic personality disorder. The psychiatrist also expressed his opinion that the veteran's prognosis for improvement was "quite poor" and that he would not respond to either therapy or punishment in the military. The psychiatrist "highly recommended that . . . [the veteran] be discharged and that he voluntarily enter therapy w[h]erever he choses [sic] to live." A May 1981 separation examination demonstrated that the veteran's psychiatric evaluation was normal and that he had no defects or diagnoses. In the same month, he was discharged from active military duty. Three months later, in August 1981, the veteran was afforded a VA examination at which time he complained of emotional problems, including feelings of nervousness. An adjustment disorder with depressive mood and alcohol dependence was diagnosed. Subsequent post-service medical records note outpatient treatment for feelings of anxiety and depression from July to December 1983. During that time, and specifically during a two-week hospitalization in October 1983, the veteran was treated for alcohol dependence and a borderline personality with a history of antisocial behavior. Between November 1983 and January 1984, the veteran was hospitalized for approximately one-and-a-half months for treatment for a mixed personality disorder with cyclothymic and borderline features as well as for continuous alcohol abuse. These diagnoses were later confirmed during a one-month hospitalization from March to April 1984, and at a May 1984 outpatient treatment session. A discharge summary from a hospitalization later in April 1984 includes diagnoses of alcohol withdrawal syndrome with seizures and a borderline personality disorder. In May 1984, the veteran was hospitalized for almost one week for alcohol dependence and an antisocial personality disorder. During a one week hospitalization in August 1984, the veteran's "long history of psychiatric hospitalizations, including the diagnosis of manic depressive illness" was noted. The diagnoses of opiate dependence, opiate withdrawal (treated and resolved), alcohol dependence, depression with suicidal ideation, and elevated liver function tests (resolved) were made. Diagnoses of alcoholism, a borderline personality disorder, an antisocial personality disorder, a sociopathic personality disorder, and a mixed personality disorder were confirmed during multiple subsequent hospitalizations between September 1984 and May 1985. Psychological testing completed in June 1985 resulted in a diagnosis of a schizotypal personality disorder. During a hospitalization (approximately one month and one week between May and July 1985) for a history of alcohol abuse (Axis I) and for a schizotypal personality disorder (Axis II), the treating physician noted that the veteran's emotional problems had been previously diagnosed as a bipolar disorder, attention deficit disorder, and a personality disorder. It was also noted that psychiatric diagnosis had not remained consistent over his hospitalization. One week after discharge, the veteran was again hospitalized for approximately three weeks (July to August 1985) for continuous alcohol abuse (Axis I) and a schizotypal personality disorder (Axis II). Subsequent hospitalizations from April to May 1986, in August 1986, in June 1987, in August 1987, and in September 1987 confirmed diagnoses of chronic alcohol dependence, a history of seizures of questionable etiology (which were later described as withdrawal seizures), a borderline personality disorder with sociopathic and aggressive tendencies, and an antisocial personality disorder. From October 1987 to March 1988, the veteran was hospitalized for treatment for an adjustment reaction with depressed mood, as well as for alcohol abuse which was in remission (Axis I diagnoses) and a mixed personality disorder with antisocial features (Axis II diagnosis). The discharge summary report from this hospitalization indicates that the veteran had been hospitalized numerous times for alcohol related psychiatric difficulties. In April 1988, the veteran was hospitalized for two days for treatment for alcohol dependence and for possible borderline personality disorder. In the following month, the veteran was again hospitalized for one week for treatment for an acute exacerbation of chronic alcohol dependence as well as for chronic anxiety and a borderline personality disorder. At outpatient psychiatric evaluations completed in June and July 1988, the impressions of alcohol dependency, borderline personality disorder, and community adjustment problem with depression were given. Between July and August 1988, the veteran was hospitalized for just more than one month for treatment for alcoholic hepatitis, alcoholism, status-post trauma of his right eye, and an anxiety disorder. An outpatient psychiatric evaluation completed in September 1988 provided the impressions of an anxiety reaction, a borderline personality disorder, and chronic alcohol dependency. An impression of a borderline personality disorder was confirmed at a November 1988 outpatient psychiatric evaluation. A mental status examination completed on admission to an almost two-week hospitalization between December 1988 and January 1989 for treatment for acute and chronic alcohol and substance abuse showed no sign of a psychosis. However, the veteran was referred to the Outpatient Psychiatry Service. Chronic alcohol dependency, atypical anxiety, and a borderline personality disorder were assessed in March and April 1989. During a three-month hospitalization from May to August 1989, the following diagnoses were made: alcohol abuse, polysubstance abuse, rule out amnestic syndrome secondary to alcohol (Axis I), borderline personality disorder (Axis II), a cyst on the right inner eyelid, and a gunshot wound to the lip and mouth (Axis III). According to a November 1990 consultation report, a psychologist explained that the veteran primarily had a character disorder, and was probably a sociopath who heavily utilized hypochondriacal defenses and sought to avoid psychological insights into his problems. It was noted that the veteran was prone to manipulation and exploitation, especially of treatment resources. In July and September 1991, the veteran was treated for panic attacks and depression. During a period of hospitalization from January to April 1992, the veteran was treated for polysubstance abuse, cyclothymic disorder, and an impulse control disorder. A borderline personality disorder and alcohol abuse were diagnosed later in April 1992. Between October and December 1992, the veteran was hospitalized for almost two months with the following Axis I diagnoses: bipolar disorder and polysubstance abuse. In January 1993, he was hospitalized for almost two weeks for treatment for the following Axis I diagnoses: alcohol dependence, organic personality disorder, anxiety disorder, and hypomania. According to the discharge summary from this hospitalization, the veteran was treated for an organic personality disorder which he described as being due to a head injury at the age of 19. Between February and April 1993, the veteran was hospitalized for almost one-and-a-half months for treatment for polysubstance abuse and a bipolar disorder. In June 1993, the veteran was treated for a bipolar disorder and alcohol abuse. In March 1994, the veteran was hospitalized for approximately one week after threatening to kill himself, destroying his mother's apartment, and attempting to kill her. The examining physician concluded that the veteran's primary discharge diagnosis was "technically an Axis II diagnosis, and it . . . [was] a narcissistic personality disorder." Axis I diagnoses include a panic disorder and a polysubstance disorder (in remission). Subsequently, between March and April 1996, the veteran was hospitalized for one month for the following Axis I diagnoses: alcohol dependence, atypical depression, and an atypical psychosis. As noted above, the veteran has received various psychiatric diagnoses. A manic depressive illness was first noted in August 1984. A diagnosis of a bipolar disorder was also made in 1992 and was confirmed on evaluations completed in the following year. Although a bipolar disorder was not noted at a March 1994 evaluation, a subsequent examination (completed during a March to April 1996 hospitalization) provided a relevant diagnosis of an atypical psychosis. What is significant about the available record is, paradoxically, what it does not show. The claims folder contains no competent medical evidence associating any bipolar disorder that the veteran may have to his active military duty or any event coincident therewith, such as the head injury described by the veteran. Competent medical evidence of a nexus between current disability and the veteran's military service is required for a finding of a well-grounded claim. See Jones v. Brown, 7 Vet.App. 134 (1994). Such evidence is lacking in this case. In other words, no one with sufficient expertise has provided an opinion that any bipolar disorder that the veteran may have had its onset during service or as the product of injury in service or continued symptoms since service. Consequently, the veteran's claim of service connection for a bipolar disorder is not well grounded. Caluza, supra. Disability Resulting from a Coma Throughout the current appeal, the veteran has essentially asserted that service connection is warranted for a disability resulting from a coma which occurred during his active military duty. In a substantive appeal which was submitted in June 1996, the veteran specified that, at the age of 19 (during his active military duty), he sustained a head injury which put him in a coma for one-and-a-half months. Following psychological testing in June 1985 which resulted in the diagnosis of a schizotypal personality disorder, the examining psychologist expressed his opinion that "[t]hese characteristics exacerbate problems in cognitive functioning related to apparent cerebral damage that resulted from two incidents of brain trauma and, possibly, a history of chronic drug and alcohol abuse." Additionally, the psychologist concluded that the findings from the tests "suggest that the two incidents of brain trauma, as well as [the] chronic substance abuse, have resulted in diffuse impairments that are compounded by his poor level of psychological and social functioning." Furthermore, in June 1991, the veteran reported having a history of a "head injury in [the] military with [a] prolonged coma." In pertinent part, a cognitive disorder secondary to a head injury was diagnosed. A reasonable reading of these post-service medical records is that the veteran has a cognitive disorder which is attributable to an in-service head injury which the veteran reported as the cause of a coma. In short, these medical opinions provide evidence of current disability and nexus to military service, which evidence is required to make the claim well grounded. Consequently, the Board concludes that the veteran's claim of service connection for a disability resulting from a coma is well grounded. See Caluza, supra. ORDER Service connection for a bipolar disorder is denied. The claim of service connection for residuals of a coma is well grounded; to this extent, the appeal is granted. REMAND As noted above, the claims folder contains some medical records which appear to associate a cognitive impairment with an in-service head injury which had resulted in a coma. However, the medical professionals who provided an opinion or relevant history as to the onset of a cognitive disorder did not specifically state that they had had access to the veteran's claims folder, especially pertinent medical records. Review of such records is particularly important in this case where the service medical records appear to be negative for complaints of, treatment for, or findings of a head injury resulting in a coma as well as where the initial post-service medical reports also fail to provide competent evidence of residuals of such an in-service injury. In this regard, a review of the service medical records which have been obtained and associated with the claims folder reflects the presence of blackouts related to alcohol abuse but does not provide any confirming evidence of a head injury resulting in a coma. In particular, the service medical records indicate that, on admission to an approximately two- week hospitalization in August 1979 for chronic alcoholism (which was found to be under control and to have existed prior to entry), the veteran reported getting drunk daily and having multiple blackouts. Examination on admission showed that the veteran was oriented times three, that his speech was slurred, that he had unintelligible thoughts, and that he was alert and cooperative. The veteran's adult illnesses included sinusitis with allergies to pollen as well as periodic stomach cramps with vomiting. No mention was made of any type of head injury or coma. A subsequently conducted examination upon admission to the Alcohol Rehabilitation Service following detoxification was essentially within normal limits with no evidence of any of the findings that were present on admission to the hospital. An undated service medical report includes the statement that the veteran had a history of multiple blackouts secondary to alcohol abuse. Furthermore, the separation examination, which was conducted in May 1981, failed to provide any evidence of residuals of a coma or head injury that may have led to a coma. In fact, this examination specifically determined that the veteran's head and neurological evaluations were normal and that he had no defects or diagnoses. Moreover, three months after the veteran's May 1981 discharge from active military duty, he was afforded a VA examination at which time he made no complaints of any residuals of a coma. His head was considered normal. No neurological disorder was diagnosed at this evaluation. In addition, a report of a one-week hospitalization in August 1984 for psychiatric and alcohol dependence treatment indicates that the veteran has a "history of alcohol withdrawal seizures, blackouts, and tremors," but no disability resulting from a coma was diagnosed. Consequently, the medical opinions that the veteran has a cognitive disorder associated with an in-service head injury which resulted in a coma appear to have been based solely upon the veteran's own reports of in-service events, without consideration of other evidence suggesting otherwise. In order to obtain a medical opinion as to the onset of any cognitive disorder which is founded on a review of all the evidence of record, a remand is required. Additionally, the Board notes that, in a January 1998 statement, the veteran stated that he was "in a neurorehabilitation program for head injured individuals." Importantly, however, records of any such treatment have not been obtained and associated with the claims folder. On remand, therefore, an attempt should be made to procure any additional relevant medical records which have not previously been obtained. For the reasons stated, this case is REMANDED to the RO for the following actions: 1. The veteran should be given an opportunity to supplement the record on appeal. The Board is particularly interested in records of treatment at a neurorehabilitation program for head injured individuals (to which he referred in the January 1998 statement). The RO should assist the veteran as necessary in accordance with 38 C.F.R. § 3.159 (1999). 2. Thereafter, the veteran should be afforded a VA neurological examination to determine the presence and etiology of any residuals of a coma caused by a head injury. The claims folder and a copy of this remand must be made available to the examiner, the receipt of which should be acknowledged in the examination report. After reviewing the file and obtaining a detailed history from the veteran, the examiner should provide an opinion as to the medical probabilities that the veteran experienced a head injury in service that led to any cognitive disability. A complete rationale should be provided for all opinions reached. Any opinion provided should be explained in light of the medical statements already of record which suggest that a cognitive disorder was caused by head trauma. 3. The RO should thereafter re- adjudicate the issue of entitlement to service connection for residuals of a coma. If the benefit sought on appeal is not granted, the veteran and his representative should be provided with a supplemental statement of the case. After the veteran has been given opportunity to respond to the supplemental statement of the case, the case should be returned to the Board for further appellate consideration. The veteran need take no action until he is informed, but he may furnish additional evidence and argument while the case is in remand status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); Booth v. Brown, 8 Vet. App. 109 (1995); and Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of this remand is to comply with governing adjudicative procedures and to obtain clarifying evidence. 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. MARK F. HALSEY Member, Board of Veterans' Appeals