BVA9500451 DOCKET NO. 92-12 819 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, variously diagnosed, secondary to a total hysterectomy with bilateral salpingo oophorectomy due to pelvic inflammatory disease. 2. Entitlement to service connection for a bladder disorder secondary to a total hysterectomy with bilateral salpingo oophorectomy due to pelvic inflammatory disease. 3. Entitlement to a total rating for compensation purposes based on individual unemployability. REPRESENTATION Appellant represented by: William C. Harrison, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. D. Jackson, Associate Counsel INTRODUCTION The veteran served on active duty from October 1977 to October 1981. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions from the St. Petersburg, Florida, Regional Office (RO). A rating decision dated in May 1990 in part, confirmed the prior denial of entitlement to service connection for a psychiatric disorder and denied entitlement to unemployability benefits. In July 1991, the Board remanded this case for further development. The issues before the Board, as reflected in the July 1991 decision, were entitlement to secondary service connection for depression, entitlement to secondary service connection for a bladder disorder and entitlement to a total disability evaluation on the basis of individual unemployability. The veteran appeared and offered testimony at a hearing held before a member of the Board in December 1992. In June 1993, the Board remanded this case for additional development. The issues before the Board, as reflected in the July 1991 decision, were entitlement to service connection for depression, entitlement to service connection for a bladder disorder and entitlement of a total disability evaluation on the basis of individual unemployability. Subsequently, the RO continued the denials in a rating decision dated in May 1994. In regards to the issue of service connection for an acquired psychiatric disorder, we note that the veteran was originally denied service connection for a psychiatric disorder on a direct and secondary basis by a Board decision dated in November 1987. At the veteran's personal hearing dated in December 1992, her representative indicated that he desired to expand the claim to include the issue of direct service connection for a psychiatric disorder. It appears from the record that veteran also contends that service connection is warranted based on secondary service connection secondary to her hysterectomy including her hormone therapy. Regardless, in light of the development of the record we find that new and material evidence has been submitted since the 1987 Board decision; therefore, we will review this issue on a de novo basis. In light of our decision concerning service connection for an acquired psychiatric disorder, the issue of entitlement to a total rating for compensation purposes based on individual unemployability will be remanded. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that due to the total hysterectomy, in particular the estrogen therapy, she now suffers from a psychiatric disability. She claims that the "estrogen enhances the adverse effects of anti-depressant medication, and reduces the effectiveness of her anti-depressant medication." She also claims that she suffers from post-traumatic stress disorder as a result of her total hysterectomy. She further contends that as a result of her total hysterectomy she now suffers from a bladder disability. Specifically, she claims that she suffers from stress incontinence and bladder instability. As such, she should be granted service connection for a bladder disorder. 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 files. 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 the evidence is in equipoise and supports a grant a grant of service connection for an acquired psychiatric disorder. However, it is the decision of the Board that the appellant has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that her claim for entitlement to service connection for a bladder disorder secondary to a total hysterectomy with bilateral salpingo oophorectomy due to pelvic inflammatory disease is well- grounded. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the agency of original jurisdiction. 2. Various VA physicians have opined that the veteran's psychiatric disability is attributable to her total hysterectomy. The evidence overall is in equipoise. 3. The evidence before the Board fails to demonstrate any pertinent findings demonstrating that the veteran currently suffers from a chronic bladder disorder. CONCLUSIONS OF LAW 1. The veteran's psychiatric disability is the proximate result of the service connected total hysterectomy with bilateral salpingo oophorectomy due to pelvic inflammatory disease. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1993). 2. The appellant has not submitted evidence of a well-grounded claim for service connection for a bladder disorder. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.303, 3.310 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, it is necessary to determine whether the appellant has submitted a well-grounded claim and, if so, whether the Department of Veterans Affairs (VA) has assisted the appellant in properly developing his claim. A "well-grounded" claim is one which is not implausible. The appellant's claim for entitlement to service connection for an acquired psychiatric disorder appears to be reasonably based. A review of the evidence further indicates that all relevant facts have been properly developed and that there is sufficient evidence upon which to fairly resolve the above mentioned issues raised by the instant case. Service medical records reveal that on several occasions during service the veteran complained of not sleeping because of nervousness. Medical treatment usually consisted of Dalmane, Benadryl or antacids. The diagnostic impressions were that the veteran's sleeping problems were situational. The veteran's service medical records contain numerous references to her seeking medical attention because of chronic pelvic inflammatory disease. In July 1981 the veteran was given a separation medical examination. The veteran complained of frequent trouble sleeping, depression and excessive worry, and nervous trouble. She stated that she had bad nerves, insomnia, and stomach pain, as well as gynecological complaints. No psychiatric diagnosis was established. In early February 1985, the appellant filed a claim for VA compensation benefits. The claims form is negative for any indication that the veteran received psychiatric treatment either during or after her military service. In March 1982, the veteran was hospitalized at the Memorial Hospital of Glendale. She gave a four-years history of recurrent severe pelvic inflammatory disease causing marked disability and pain. During her hospitalization the veteran underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Later that month, the veteran's mother called the veteran's physician. The veteran was hyperventilating and had palpitations. Valium was prescribed. Three days later, the veteran was examined by her physician. It was reported that the veteran had no energy but was eating and moving about. The veteran spoke of stress at her home. In May 1982, the veteran was examined by her private physician. Both examinations were negative for any indication that the veteran had a psychiatric disorder. In June 1985, the veteran underwent a VA examination. She reported that subsequent to her surgery, she had difficulty with depression and anxiety, and that she still had "spells" at times. The report of medical examination is negative for any psychiatric diagnosis. VA outpatient treatment records developed between December 1985 through April 1986 relate that subsequent to her hysterectomy she began to drink heavily and to occasionally use marijuana and hashish. In December 1985, the veteran reported that she had periods of agitation, anxiety, panic reactions, chest pain, hyperventilation and depression. The differential diagnoses included: Dysthymic disorder, affective disorder secondary to hormone imbalance, anxiety neurosis, and alcohol abuse. She was referred to the social work service for a discussion of detoxification and alcohol treatment. In early January 1986 the veteran was referred to the medical department from the mental health clinic. It was recorded as clinical history that the veteran was currently on a substitution therapy for bilateral oophorectomy and hysterectomy. The veteran complained that she was having night sweats, weight fluctuations, hot flashes, instability, and depressive mood swings. Physical examination was essentially normal. The diagnostic impression was to rule out hypothyroidism and diabetes mellitus. Appropriate laboratory tests were ordered. In late January 1986, the veteran complained of still having hot flashes, sweats and tension. The veteran had anger and hostility toward her problem. In early February 1986, the veteran was given psychological testing. The examining psychologist's opinion was that the test productions included clinically significant characteristics too extensive to be well included in any single diagnosis, save one of the schizophrenic disorders, and this diagnosis was not satisfactory because the quality of psychosis had been absent. Some other catch-all diagnosis might be suggested such as borderline personality disorder, but in his opinion this was ruled out by the veteran's stable functioning through all of her school years, her eight years of marriage as well as her completion of a four-year military tour of duty. The examiner noted that physiological hormonal imbalance was created through her total hysterectomy and attempts at hormonal replacement therapy afforded perhaps a better way to account for the wide array of symptoms of disturbed affect and thinking, which was not fully psychotic. The overall conclusion was "considerable similarity to mixed anxiety disorder and borderline personality disorder characteristics intensified to a level of clinical manifestation in an otherwise normal personality due to changes in somatic factors and stress." Also in February 1986 the veteran returned to the medical clinic. The veteran continued to have hot flashes, irritability and mood changes. The impression was to rule out hypothyroidism and low estrogen. In late February 1986 the veteran returned to the mental health clinic. She continued to have fears, anxiety and paranoid ideations. The assessment was to rule out psychosis and hormonal imbalance. It was recommended that she enter a detoxification program. In late February 1986, the veteran was diagnosed as having an intermittent explosive disorder, alcohol abuse and a general anxiety disorder. It was also stated that a determination should be made as to whether a hormone imbalance or a schizo-affective disorder was the proper diagnosis. It was noted that they were still waiting for the veteran's hormonal workup. In May 1986, the veteran returned to the mental health clinic. It was noted that her general appearance was much improved. The assessment was mixed psychiatric disorder. Later that month she complained of financial problems and not being able to sleep. The assessment was dysphoria and anxiety with sleep difficulty. A Board decision in November 1987 denied service connection for a psychiatric disorder on a direct and secondary basis. The Board determined that her inservice episodes of psychiatric complaints were situational and acute and transitory. Also, the records did not show that she had a psychiatric reaction to her hysterectomy, but that her alcohol and drug addictions were a result of her unemployment and variant lifestyle. VA outpatient records developed between December 1987 and October 1989 show that the veteran continued treatment for alcohol abuse. She reported symptoms including depression, insomnia, crying, lack of motivation and overeating. VA records dated in March 1991 show that the veteran continued to seek treatment. She was diagnosed with major depression secondary to her hysterectomy. Correspondence from the veteran's private physician dated in may 1991 also diagnosed recurrent severe major depression and post- traumatic stress disorder. Pursuant to a Board remand, the veteran underwent a psychiatric examination by a Board of two psychiatrists in December 1991. The diagnosis was major depression, manifested by dysphoric mood, loss of interest, loss of pleasure sense, impaired concentration, anger, irritability, easy fatigability, bulimorexia, insomnia and low self-esteem. The examiner commented: "As to the question of relationship between her psychiatric disorder and hysterectomy, Estrogen use, her melasma, it is impossible to say that her depression was caused by these factors mentioned above. However, it is likely that [the] hysterectomy, Estrogen use and melasma may be exacerbating conditions of her current depression. The above conclusion is based on the fact that [the] hysterectomy was done about ten years ago, and there were various inter-current situations since then, such as death of her mother, alcohol abuse problems, failure of her second marriage, etc." Pursuant to a second Board remand the veteran again underwent a psychiatric examination by a board of two psychiatrists. In October 1993, the veteran underwent examination. The veteran reported her past history. She was oriented to time place and person. She stated that she was down in the dumps and unmotivated. She further related that she cried for no reason. There was no evidence of delusions or hallucinations. The examiner commented in pertinent part that it was certainly conceivable that estrogen had resulted in depression. The examiner also noted that it was important to note what effect the hysterectomy had on her self esteem. In fact, the examiner expressed the opinion that her depression is directly related to her total hysterectomy. The diagnosis was; Axis I, (1) dysthymia versus major depressive disorder secondary to the loss of self esteem from hysterectomy; (2) Possible post-traumatic stress disorder related to the experience of the hysterectomy. Axis II, possible borderline personality disorder. A March 1994 examination revealed that the veteran was hysterical and markedly tearful throughout the interview. She related her history and noted a rape that occurred subsequent to her hysterectomy. Her mood was depressed with a sad affect. Her speech was tearful and hysterical but generally goal directed. She was awake, alert and oriented to person, place and time. There was no cognitive deficit noted. Her insight and judgment was fair. There were no homicidal or suicidal ideations. There was no evidence of hallucinations. The diagnosis was; Axis I, (1) post-traumatic stress disorder, mild to moderate and (2) rule out major depression. Axis II, histrionic and borderline personality traits. A private psychiatric report dated in April 1994 shows that the veteran reported her past medical history. She also noted that she had been raped in 1982. The veteran was reported by the examiner to be free of depression, suicidal ideation, sleep and appetite disturbance, and decreased energy. A grant of secondary service connection is warranted if a disorder is shown to be proximately due to or the result of a service-connected disorder. In this regard, service connection has previously been established for a total hysterectomy with bilateral salpingo oophorectomy due to pelvic inflammatory disease. In the present case the veteran asserts that she has developed a psychiatric disability due to her total hysterectomy, in particular the estrogen therapy. There is of record the clinical conclusion of a VA physician that she is depressed due to the estrogen therapy. Additionally, another VA physician has commented that her depression is related to the total hysterectomy. Further, the veteran has submitted pharmacological reports that state that depression may be a side effect of estrogen. In contrast, the claims file also discloses various diagnoses including personality disorder, anxiety disorder, major depression, alcohol abuse and post-traumatic stress disorder. We acknowledge that there are conflicting interpretations as to the whether there is a cause and effect relationship between the service connected residuals of the total hysterectomy and her psychiatric disorder, however diagnosed. Although, there are various and sometime conflicting opinions as to the etiology of her psychiatric difficulties, we find that overall the comments offered by examiners tend to suggest a causal relationship. As such, we find the evidence to be in equipoise. Accordingly, in light of the aforementioned medical opinions and the entire record before the Board and resolving any existing element of doubt in favor of the veteran, it is found that a grant of secondary service connection for an acquired psychiatric disorder, variously diagnosed, is warranted. II In regard to the veteran's claim for service connection for a bladder disorder, the service medical records are negative for complaints or treatment for such a condition. The veteran contends that she has developed a bladder disability secondary to her total hysterectomy. As noted, previously, a grant of service connection on a secondary basis for a disability requires that the evidence demonstrate such a cause-and-effect relationship between the service-connected disorder and the disability for which secondary service connection is sought. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1993). The threshold question to be answered in this case is whether the appellant has presented evidence of a well-grounded claim; that is, one which is plausible. If she has not presented a well- grounded claim, her appeal must fail and there is no duty to assist her further in the development of her claim. 38 U.S.C.A. § 5107(a) (West 1991), Murphy v. Derwinski, 1 Vet.App. 78 (1990). As will be explained below, it is found that her claim is not well-grounded. A review of her medical history in regard to her bladder shows that in June 1985, the veteran underwent a gynecological examination. It was noted that the bladder was mildly tender. In December 1987, the veteran complained of stress incontinence. She related that this had been present since her hysterectomy. The provisional diagnostic impression was stress incontinence secondary to her total hysterectomy. She continued to complain of incontinence and urinary frequency. In May 1988, she underwent a genitourinary examination. The diagnostic impression was stress incontinence, etiology unknown. In June 1988, she underwent a gynecological examination. There was no cystocele or rectocele present. The diagnostic impression was unstable bladder. A June 1988 intravenous pyelogram found no bladder outlet obstruction. A VA outpatient report dated in September 1988 shows that the veteran related that she experienced urge incontinence and nocturia. The diagnostic impression was detrusor dyssynergia and trigonitis. Pursuant to a Board remand, the veteran underwent a urological examination in November 1991. The veteran reported that there was no stress incontinence and no urgency incontinence. On examination of the pelvic area there were no masses or urethral abnormalities. A cytometric study was conducted and the diagnostic impression was possible unstable bladder. In a VA outpatient record dated in November 1993, the veteran complained of feeling pressure over her bladder. She had the urge to urinate often and reported occasional dribbling. She further reported frequent urination, up to 40 times a day depending on her water intake. She denied dysuria or hematuria. On examination there was no incontinence or evidence of detrusor dysergia. The pelvic region was nontender. The bladder had excellent capacity of 420 ml. There was no evidence of interstitial cystitis. The gynecology/urology report indicates that there was no evidence of exudate, hyperpnea, polyps or tumors. Cytoscopy, urethroscopy and urodynamics studies were normal. A pathological diagnosis, assessment or impression regarding the bladder was not rendered. As referred to above, the threshold question to be answered in this case is whether the appellant has presented a well-grounded claim, that is, one which is plausible when the contentions and the evidentiary records are viewed, in the light most favorable to that claim. If she has not, her appeal must fail. 38 U.S.C.A. § 5107(a) (West 1991). In reviewing the veteran's record, we note that there is no evidence that is clinically supportive of her allegation that she has a bladder disability secondary to a service connected disability. The appellant has not presented any probative evidence, medical or otherwise, that would indicate that she currently suffers from a bladder disability. Although there was noted bladder instability in 1991 the most recent neurogenic studies are negative. Additionally, the most recent cytometric studies and cytoscopic examination were considered normal. There was no incontinence and there were no abnormalities noted on physical inspection. A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. See 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1993); Rabideau v. Derwinski, 2 Vet.App. 141,143 (1992). In light of the absence of a current diagnosis of a bladder disability, it would be unnecessary to discuss the prospects for the existence of an etiological relationship between such a disorder and the veteran's service connected disability, and the claim is not well grounded. The veteran is free to submit evidence at a future date, in the event such a disability might become evident, and she will not be confronted by the procedural obstacle of a final Board decision adverse to the stated issue. ORDER Service connection on a secondary basis for a psychiatric disability, variously diagnosed, is granted. The appellant's claim for service connection for a bladder disorder is dismissed inasmuch as it is not well-grounded. REMAND In light of our allowance of service connection for an acquired psychiatric disorder, the issue of a total rating for compensation purposes is being REMANDED to the regional office pending further rating and consideration: The RO should address the issue of a total rating for compensation purposes based on individual unemployability taking into consideration all of the veteran's service- connected disorders, which now include an acquired psychiatric disorder. When the requested action has been completed and if the determination is adverse to the veteran, the veteran should be afforded a reasonable period of time in which to respond to a supplemental statement of the case. Thereafter, subject to current appellate procedures, this case should be returned to the Board for further appellate consideration if appropriate. The veteran need not take any action unless she is further informed. The purpose of this REMAND is to allow for further development of the record and no inference should be drawn from it regarding the final disposition of this claim. JEFF MARTIN 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) (1993). 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.