BVA9501987 DOCKET NO. 93-17 155 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, characterized as bipolar disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. K. Mulroy, Associate Counsel INTRODUCTION The veteran had active duty from December 1980 to December 1983, and from November 21, 1990 to April 1991. In July 1992, the veteran was denied service connection for bipolar disorder by the Little Rock, Arkansas, Regional Office (hereinafter RO). He has appealed to the Board of Veterans' Appeals (hereinafter the Board). The veteran is represented by the American Legion. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that although he acquired his psychiatric disorder after his first period of active duty and prior to his second period of active duty, it was aggravated by his second period of service. He asserts that he was denied his medication and was under excessive stress during the second period of service, which caused his condition to deteriorate. Therefore, he maintains that his condition increased in severity and that he is entitled to service connection for this 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 file(s). 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 a preponderance of the evidence is against the claim of entitlement to service connection for an acquired psychiatric disorder, characterized as bipolar disorder. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. Between his first and second periods of active service, the veteran was diagnosed with and treated for bipolar disorder. His treatment included a prescription for Lithium, and he was noted as doing well on medication. 3. During his second period of active service, the veteran's medication was discontinued, and his premedication emotional problems recurred. After resuming his medication, the veteran's symptoms were noted as under good control. 4. Over the complete second period of the veteran's active service, there is not shown to have been an increase in the severity of the basic underlying pathology associated with bipolar disorder, despite a temporary exacerbation in late 1990 and early 1991. CONCLUSIONS OF LAW 1. There is clear and unmistakable evidence that the veteran's acquired psychiatric disorder, characterized as bipolar disorder, existed prior to service, and the presumption of soundness with regard to the acquired psychiatric disorder is rebutted. 38 U.S.C.A. § 1111 (West 1991). 2. The veteran's preexisting acquired psychiatric disorder, characterized as bipolar disorder was not aggravated by service. 38 U.S.C.A. §§ 1131, 1153 (West 1991); 38 C.F.R. § 3.306 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107. That is, the Board finds that the veteran has presented a claim that is plausible. The Board is satisfied that all reasonable efforts have been made in helping the veteran prove his claim. There is no other indication of outstanding evidence, and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107. In determining whether service connection is warranted for a disability, the Department of Veterans Affairs (hereinafter the VA) is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet.App. 49 (1991). Service connection may be established for disability resulting from injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury or disease. 38 U.S.C.A. § 1131. Regulations also provide that service connection may 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). A veteran is presumed in sound condition except for defects noted when examined and accepted for service. To rebut this presumption, there must be clear and unmistakable evidence demonstrating that the disability existed before service. 38 U.S.C.A. § 1111. A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in the disability during service, unless there is a specific finding that the increase is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. As previously noted, the veteran served from December 1980 to December 1983, and from November 1990 to April 1991. Service medical records from his first period of service are silent regarding diagnosis of or treatment for an acquired psychiatric disorder. In VA outpatient treatment records dated in June 1988, it was noted that the veteran reported treatment at a private facility since June 1986 for manic depression and bipolar, manic type; reported emotional problems since age five; and reported receiving therapy as a ninth grader through the start of his senior year. His symptoms reportedly included sleep disorder and hyperactivity. The diagnosis of bipolar, manic type was continued by the VA physician, and he was treated with Lithium. In follow- up treatment records dated in September 1988, it was noted that he was doing well. During a periodic physical for reserve purposes in August 1990, the veteran responded in the negative to an inquiry as to whether he ever had, or was currently experiencing, psychiatric symptoms. He did report taking medication, and having been seen by a psychiatrist, since June 1989 for a metabolic imbalance. It was specifically indicated that the veteran denied an affective disorder. Currently, he was clinically evaluated as normal psychiatrically. On November 30, 1990, the veteran was referred for psychiatric evaluation as he was noted to be on low dose medication for bipolar disorder and it was questioned whether he was fit for deployment. He was evaluated on December 5, 1990, at which time it was noted that the veteran reported one episode of anxiety, irritability, decreased need for sleep, and increased energy in 1986, which lasted three weeks. Treatment with Lithium resolved his symptoms. He reported that he had been off and on the medication for the last four years and did not have recurrence of the symptoms when off the medications for short periods of time, such as during his two week training periods of military service. Current assessment was bipolar disorder not otherwise specified with one episode of hypomania. It was noted that his civilian physician was to be contacted to confirm his reported history, and the veteran was given a permanent S2 profile and taken off his medications, to be monitored on an outpatient basis. A medical board report, dated in August 1991, substantially reiterated the aforementioned history. When referred for psychiatric evaluation [in early December 1990], it was noted that changes in the veteran's behavior had been observed by members of his unit, including the unit chaplain, who was also the veteran's preacher at home, and had known him for many years. The unit surgeon had also reportedly observed the veteran, noting rambling speech and tangentiality. On current mental status examination, the veteran was alert and oriented, with no looseness of associations, and the veteran did not exhibit delusions or hallucinations. His speech was slightly pressured, and thought processes showed some circumstantially. Due to reports of many observers that the veteran's symptoms had recurred after being taken off medication, the decision was made to restart him on lithium. He was noted to have "responded well" to his medication and did not exhibit any further symptoms. However, as his circumstances required constant medication management and monitoring, he was considered nondeployable in the extreme conditions of a combat zone. He was also precluded from reclassification to any other military occupation specialty. The physician diagnosed bipolar disorder, not otherwise specified, severity was moderate, treated, in remission, which existed prior to service and was not aggravated by service. The Medical Board referred the veteran to the Physical Evaluation Board, and the veteran was released from active service in April 1991. In VA outpatient treatment records dated from April to December 1991, it was noted that the veteran's bipolar disorder symptomatology was under good control with treatment of Lithium. In a record dated in December 1991, it was noted that he was experiencing increased anxiety with the Desert Storm operation, and he was started on an anxiolytic agent, as well as being continued on Lithium. In a VA examination dated in April 1992, it was noted that the veteran reported being diagnosed with bipolar disorder in a private facility in 1986, that he was currently employed as a security guard at a country club, was feeling fine when compliant with his medication, and reported intermittent periods of agitation, insomnia, and alcohol abuse. Upon examination, the physician noted that the veteran was pleasant, cooperative, well groomed and casually dressed; affect was bright and expressive; speech was mildly pressured; mood was reported as good; and there was no psychotic thought disorder and no suicidal thinking. The diagnosis was bipolar disorder in partial remission. At a hearing dated in May 1993, the veteran testified as to the history and current condition of his psychiatric disorder. Specifically, he stated that when he went off his medication during his second period of service, he did not function well and was under excessive pressure in his job as a clerk. He testified that now that he had resumed taking Lithium, his condition was the same as it was prior to Desert Storm. He stated that his problems were aggravated during service because he tried hard to meet standards and had stressful assignments. He also presented a letter from his chaplain which is dated in October 1992. In this statement, it was commented that the chaplain had known the veteran for four years, both as his (civilian) pastor, and as his chaplain in the National Guard. He described having been in close contact with the veteran during (his second period of service) due to the difficulties the veteran was having emotionally. His bipolar disorder was described as "severely aggravated" by the stresses of his first two months of service, and he was having persistent difficulties adjusting to civilian life since service. Comments on the periodic examination in August 1990 were somewhat equivocal in terms of assessing whether a psychiatric defect was noted on that occasion, with it also not being clear whether the periodic examination constituted an induction examination for purposes of 38 U.S.C.A. § 1111. However, the VA outpatient records developed in 1988 clearly document psychiatric pathology during the interval between the veteran's two periods of service. Given the findings also noted during the second period of service, and the fact that the veteran concedes a preservice (second period) psychiatric history, the "presumption of soundness" is clearly and unmistakably rebutted. The question for the Board, therefore, becomes whether the veteran's preexisting psychiatric disorder was aggravated by service. As previously noted, a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service unless there is a specific finding that the disability is due to the natural progression of the disease. In this case, the evidence shows that the veteran exhibited unusual behavior in service when not under a medication regime. While in service and off medication, the record reflects an exacerbation of his symptoms. However, with a return to medication, the veteran's symptoms were clinically noted to have subsided. The clinical evidence developed during service, as well as a review of his medical history and contact with the psychiatrist treating the veteran prior to service, culminated in an opinion expressed by the evaluating psychiatrist that the veteran's problems were not aggravated by service. The clinical evidence developed since service also does not refer to an increased level of psychopathology having been derived from, or precipitated by, the veteran's relatively brief second period of service. Accordingly, the Board concludes that entitlement to service connection for an acquired psychiatric disorder has not been established. Consideration has also been extended to the veteran's hearing testimony and the 1992 statement from his chaplain/pastor. While the information furnished is found to be credible, the probative value of conclusions furnished by these individuals, to the effect that psychiatric pathology was permanently aggravated by service, is lessened in view of the fact that neither is a medical health care professional. While fully capable of setting forth observations and descriptions of behavior, to draw clinical conclusions from such activity would be outside the realm of the lay person's recognized capacity. Espiritu v. Derwinski, 2 Vet.App. (1992). In considering the veteran's claim, the Board has been mindful of the doctrine of granting the veteran the benefit of any doubt which might exist concerning any matter pertinent to his claim. Regarding his claim, the evidence is not found to be sufficiently in equipoise to raise such a doubt. 38 U.S.C.A. § 5107. ORDER Service connection for an acquired psychiatric disorder, characterized as bipolar disorder, is denied. 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. 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.