Citation Nr: 0000327 Decision Date: 01/06/00 Archive Date: 01/11/00 DOCKET NO. 94-27 881 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for a psychiatric disorder. 2. Entitlement to service connection for a seizure disorder. REPRESENTATION Appellant represented by: COLLEEN ROGERS LOSI WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechter, Associate Counsel INTRODUCTION The veteran served on active duty from March 13, 1975, to April 4, 1975. The appeal arises from the November 1993 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York, denying service connection for a seizure disorder and finding that no new and material evidence had been submitted to reopen a claim for service connection for a psychiatric disorder, which had been previously denied by an unappealed rating decision of July 1975. In June 1994, in the course of appeal, the veteran testified before a hearing officer at the RO. A transcript of that hearing is included within the claims folder. In his decision of November 1994, the hearing officer determined that new and material evidence had been submitted to reopen the veteran's claim for service connection for a psychiatric disability, but denied service connection for this disability. The previous denial of service connection for a seizure disorder was confirmed and continued. The case was remanded by the Board in August 1996, and again in October 1997, for further development of the appealed claims. The October 1997 Remand incorrectly stated that a VA psychiatric examination was not conducted as requested in the August 1996 remand. The RO subsequently pointed out that a VA psychiatric examination, responsive to earlier questions posed by the Board, was conducted in May 1997, and was of record at the time of the October 1997 Remand. The Board acknowledges its error in this matter. A further psychiatric examination was neither conducted nor required. FINDINGS OF FACT 1. An acquired psychiatric disorder, diagnosed on VA examination in May 1997 as major depression with psychotic features, developed in service. 2. There is no current objective clinical evidence of the existence of a seizure disorder. 3. A seizure disorder was not present in service. CONCLUSIONS OF LAW 1. A psychiatric disorder was incurred in wartime service. 38 U.S.C.A. §§1110, 5107 (a) (West 1991). 2. A seizure disorder was not incurred in or aggravated by wartime service. 38 U.S.C.A. §§1110, 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Factual Background The veteran served on active duty from March 13, 1975, to April 4, 1975. Prior to service, in August 1974, the veteran underwent private emergency treatment for injuries sustained in an automobile accident. The veteran was reportedly a passenger in an automobile that struck a tree. Injuries sustained for which he sought treatment included fracture of the nose and laceration to the lip and nose. Treatment included both deep and superficial sutures to the upper lip. Skull X-rays revealed no abnormalities, and an echoencephalogram revealed no shift of the midline structures. No neurological or psychological abnormalities were reported. In a report of medical history for service enlistment in January 1975, the veteran reported suffering a head injury and attempting suicide previously. Specifically, he reported suffering a concussion and a broken nose in an automobile accident in August 1974, with headaches for two months thereafter. He also reported a suicide attempt in December 1974 using cold tablets, treated with an emetic. He reported being hospitalized for three days following that attempt, with a neuropsychiatric assessment that he had been depressed due to employment difficulties. On a January 1975 medical examination report for service enlistment, the veteran was found to be psychiatrically normal. However, a February 1975 notation on that report found the veteran to be medically disqualified from Air Force service by reason of his history of attempted suicide. The purpose of the examination report was then changed from Air Force enlistment to Regular Army ("RA") enlistment. In service on March 21, 1975, on the third day of basic training, the veteran was examined by a behavioral science specialist upon complaints of pressure in the head, extreme nervousness, lack of sleep with awakening two or three times during the night, and nausea. In a questionnaire, the veteran reported that he had previously seen a psychiatrist or counselor due to nervousness. He also reported that he had been scheduled to see a psychiatrist but instead enlisted in the Army. He reported that he had been a good boxer prior to being knocked on the head in an automobile accident at 50 miles per hour in which his vehicle hit some trees. He reported attempting suicide in December 1974 and being rejected for admission into the Air Force. The examiner noted that the veteran was slightly disoriented as to the reason for the interview. The examiner assessed that the veteran was moderately depressed and severely anxious, though he apparently denied suicidal ideation. The examiner recommended discharge from service based on a chronic and severe character and behavior disorder. In a further statement on March 24, the same specialist added that while there were no signs of a thought disorder, the veteran's character and behavior disorder was manifested by low stress and frustration tolerance, poor school adjustment, poor interpersonal relationships, and lack of motivation. He noted that due to the current severity of the veteran's condition, the veteran would not benefit within a reasonable time from further training, transfer, or treatment. The behavioral science specialist determined that the veteran was "psychiatrically cleared to be separated from the service under the appropriate administrative regulations." While the veteran was in service, in letters dated March 25, 1975 and March 26, 1975, the captain in command of the veteran recommended that the veteran be discharged from the Army. The March 25 letter informed that the veteran lacked the ability to adjust to a military environment and was unable to function under any disciplined circumstances, noting the veteran's very low tolerance to slight pressures such as corrective criticism. That letter noted that the veteran had a history of suicidal incidents, most recently in December 1974. The officer concluded that the veteran had no desire to remain in service and that further service would benefit neither the veteran nor the military. The March 26 letter informed that the veteran appeared very depressed and nervous during an interview, and had no desire or ability to be a soldier. A March 31, 1975 letter from the Headquarters U.S. Army Training Center, Fort Dix, New Jersey, informed that the veteran was approved for processing for separation from service. In an April 1975 letter from the Chief, Enlistment Branch, Headquarters U.S. Army Training Center, Fort Dix, New Jersey, the veteran was informed that the reason for his separation from service was "miscellaneous-general (trainee discharge program) [....] Not eligible for immediate reenlistment." The veteran underwent VA hospitalization from April 16, 1975, to April 24, 1975, for a primary complaint of pain in the left ear. He was noted to have been inducted into the Army approximately six weeks prior. A history was noted of the veteran getting into a fight and being struck above the left ear approximately two weeks prior to the hospitalization. The veteran reported that the area around his left ear had been bruised and he had been shaken up by the incident, such that he noticed a change in the way he dealt with people of authority following the incident. He reported that he had been fearful and began crying when trying to explain to his Lieutenant about the incident. He reported that he had then been sent to the mental hygiene clinic at the base and was separated from service one week later. The veteran complained of persistent pain in the ear and occipital headaches. Findings upon physical examination were essentially within normal limits. The head was normocephalic and atraumatic. The tympanic membranes were intact bilaterally though somewhat difficult to visualize. There was no sign of otitis media, and no evidence of trauma to the left ear except for a light inflammation of the external ear canal. Neurological examination was within normal limits. Skull X-rays showed no evidence of recent fracture, and there was no increased intracranial pressure or abnormal calcifications. Echoencephalogram showed no significant shift to midline structures. Electroencephalogram (EEG) showed a few positive spikes suggestive of an abnormality in the thalamic, hypothalamic region, but the spikes were typical of those seen in patients with hyperactive and aggressive behavior. Ear, nose, and throat examination identified no abnormalities, and audiometry testing showed no hearing deficits. However, the veteran remained acutely anxious throughout the hospitalization, with difficulty sleeping. Discharged diagnoses included status post trauma to the left ear, occipital headache, and anxiety neurosis with dissociative reaction. On April 28, 1975, the veteran underwent an intake interview with VA social services for outpatient treatment. The examiner noted a history of service for 22 days followed by a medical discharge for psychiatric conditions. The veteran reported that while in service he had been attacked by four or five others and received a karate chop above the left ear, with his mental problem beginning after that blow, including severe headaches every day, earaches in both ears, and crying spells when spoken to by others or when given an order by a military superior. The veteran's VA hospitalization post service was noted. The examiner noted that it had reportedly been the ear, nose, and throat specialist's opinion during that hospitalization that the veteran's ear pain could not be attributed to the slight swelling in the left ear. The veteran complained of recently not being able to sleep well, drooling saliva when sleeping, and breaking things unintentionally due to sudden unexplained jolts of his body. He also reported a peculiar desire to hurt small children, and a resigned and apathetic attitude toward his life. He reported also recently having periods of anxiety during disagreements with his wife. The veteran reported varied employment prior to service, including as a painter and a baker, last working as a baker in March 1974 and being unemployed thereafter until his Army service. The examiner noted that the veteran was relevant, coherent, and cooperative, with normal affect. At a May 1975 VA psychiatric outpatient treatment, identified problems included difficulty sleeping, fears of loss of control over angry impulses toward others, blackouts about which he claimed to have no recollection, marital problems, and unemployment. The veteran reported that in his last blackout three weeks prior he wrecked furniture in his house. The examiner noted that an EEG conducted on April 28, 1975, had not been normal, but rather showed a few positive spikes suggesting an abnormality in the thalamic-hypothalamic region. The examiner noted that there were no definite epileptiform discharges observable on the EEG, and that the observed spikes were consistent with persons with tendencies toward hyperactive and aggressive behavior. During VA outpatient treatments from June 1975 to August 1975, the veteran was noted to be preoccupied with his perceptions of loss, being fearful, and being cowardly, relative to his prior identity as a boxer and his father's identity as a Marine. Other noted problems included recurrent or persistent headaches, sleep impairment, and blackouts. In June 1975 upon VA psychiatric outpatient treatment, a trial of Dilantin was begun "purely on the basis of the EEG report." In July 1975 upon VA outpatient treatment, headaches and feeling sick were associated with drinking and loss of memory of wrecking his bathroom and hurting himself. The possibility of pathological intoxication was suggested. In July 1975 upon VA outpatient treatment, additional identified problems were moderate depression accompanied by headaches and crying spells. An October 1975 VA treatment summary, upon transfer of the veteran to a mental health clinic following outpatient treatment from May 1975 to October 1975, informed that the veteran's diagnoses included status post trauma to the left ear, occipital headache, and anxiety neurosis with dissociative reaction. Identified problems included difficulty sleeping, aggression, fear of loss of control over angry impulses, blackouts (though none were observed since June 1975), marital difficulties, unemployment with financial stress, depression, headaches, and excessive alcohol consumption. Later in October 1975, the veteran was hospitalization for a single day at a VA facility, to facilitate placement in outpatient treatment. The veteran requested the outpatient treatment to stop drinking. A history of heavy alcohol consumption for several years was noted. Diagnosed were habitual excessive alcohol consumption, and a history of anxiety reaction. From April 21, 1976, to April 22, 1976 - over one year subsequent to his separation from service - the veteran underwent VA hospitalization for a diagnosed overdose of Valium and Phenobarbital. Also diagnosed were passive- aggressive personality disturbance and history of seizure disorder. In March 1981 the veteran was briefly hospitalized for complaints of being increasingly depressed since being out of work, with increased alcohol consumption and much combativeness. The veteran was fearful that he would harm others. By the end of the hospitalization, there were no signs of delirium tremens, the veteran was not lethal, and he was calm and no longer combative. In a June 1983 examination report by K. C. Lall, M.D., a private physician, the veteran was noted to have been referred for a seizure disorder. A history was noted of seizures since 1975, when the veteran was reportedly hit on the head and passed out for a few hours, with seizures commencing thereafter, and the veteran then discharged from service due to those seizures. The veteran reported that he was thereafter treated at the VA hospital in Buffalo, New York, including with Dilantin and Phenobarbital, for three years. He reported that he subsequently had additional seizures, most recently one month prior to the current examination. He reported undergoing a myelogram, and thereafter having grand mal seizures. The veteran also reported injuring his back severely in a drilling work accident, with pain radiating down into the legs thereafter. The examiner noted that there was also a significant past history of hypertension and diabetes, a history of being a boxer with blows to the head on multiple occasions, and a history of one or two automobile accidents in which the veteran lost consciousness. Objectively, no neurological deficits or signs of dysfunction were identified. There was only a slight limp on the left. Pending a myelogram, the examiner prescribed Dilantin and Phenobarbital based on the veteran's history of seizures. A June 1983 medical report by V. Kuman, M.D., assessed, in pertinent part, "seizure disorder - post traumatic epilepsy." However, it appears that Dr. Kuman merely carried forward that assessment, as the medical record included no report of Dr. Kuman's examination or no medical findings. Rather, Dr. Kuman informed that Dr. K. C. Lall was seeing the veteran for the seizure disorder. In a July 1983 letter, K. C. Lall, M.D., informed that a head CT scan and an EEG were recently performed and found to be within normal limits. The examiner noted that the veteran recently was unable to hold anything in his left hand, and was found to have left radial nerve palsy. In October 1987 the veteran underwent hospitalization at the Erie County Medical Center for alcohol abuse out of control for the prior year, requesting assistance to stop drinking. At an intake interview the veteran reported social patterns included consuming a 12-pack to a case of beer per day for the prior five years, and use of cocaine every other week for the prior four months. In March 1989 the veteran was hospitalized at Millard Fillmore Hospital over a period of three days to evaluate and treat him for a reported seizure disorder. The veteran was noted to have a history of seizure disorder since 1975 treated with Dilantin and Phenobarbital. He was also noted to have been out of work for the past year with a history of lower back pain. A history of depression was also noted. The veteran reported that the next day he developed a free sleep seizure while falling asleep. He reported that these free sleep seizures recurred the following few days, each lasting only a few minutes and manifested by generalized motor activity. The veteran was taking Voltaren and Trazodone at the time of admission. Objectively, the veteran was well developed and well nourished and in no acute distress. Physical and neurological examinations identified no deficits or signs of dysfunction. The veteran's initial Dilantin level was below therapeutic at 7.4. Upon neurological consultation, the veteran was examined and a myelogram was conducted. That consulting examiner diagnosed L5-S1 radiculopathy, physiologic myoclonic jerks, and headache which was atypical, probably musculoskeletal in origin. The consulting examiner recommended an EEG to rule out a seizure disorder. At Millard Fillmore Hospital in April 1989, an electroencephalogram was conducted with photic stimulation and hyperventilation. The consulting EEG examiner assessed that the EEG was essentially normal for the veteran's age, with a few abnormalities noted which were generally observable in normal individuals and a small percentage of epileptics, so that the abnormalities were not clearly epileptic in etiology, and a clinical correlation would be required to determine the presence of epilepsy. Accordingly, the veteran's Dilantin was discontinued. The final diagnosis was seizure disorder ruled out. In January 1990, J. J. Maurizi, M.D., examined the veteran for a reported injury to his back in the course of post- service work. The veteran reported a history of depressive neurosis in 1974 and seizure disorders stemming from an injury in 1975. He also reported a radial nerve injury sustained as a boxer. The veteran reported that from 1970 to 1973 he was a boxer and had had a number of bouts. He reported that in December 1974 he had been admitted to E. J. Meyer Hospital for treatment of a depressive neurosis and an overdose. He reported suffering a head injury in service followed by a number of grand mal seizures, eventually leading to his discharge from military service due to the seizure disorder, with VA follow-up thereafter, with a treatment regimen followed for three years including Dilantin, Phenobarbital, and Valium. He reported having a seizure in 1989 after being free of seizures for approximately eight years, but with physicians deciding not to resume treatment with Dilantin and Phenobarbital. He reported that at times he experiences unusual sensations of lightheadedness. He also reported suffering from lightheadedness and dizziness following performance of invasive procedures such as myelographic examination. Noted was a history of an auto accident in October 1985 in which the veteran reportedly suffered a cerebral concussion and severe back pain. Also noted was a history of radial nerve palsy on the right which developed in July 1983. The examiner apparently carried forward diagnoses of depressive neurosis and seizure disorder, as the record included no report of examination or findings for either of those conditions. From November 1992 to December 1992 the veteran underwent VA hospitalization for complaints of multiple problems. The veteran was noted to have had chest pain prior to admission. The veteran reported episodically drinking a few cases of beer two to three times per week, and having a $300-per-day cocaine habit. He was also noted to have been unemployed since a 1987 back injury at work, and to do anything short of paying for it to get his cocaine. He was also noted to have been separated from his wife for two to three years. He reportedly was living with his father, who was very sick, until one week ago when his father was hospitalized. The veteran had been homeless for the prior week. A history of seizures was noted, which reportedly was in remission, though the veteran was taking no anti-seizure medications. He reportedly attempted to slash his wrists three to four days prior to the hospitalization. Objectively, the veteran was fairly nourished with fair attention to hygiene and grooming. Affect was very restricted but appropriate to content, speech was melancholic and coherent, and mood was depressed. There was no formal thought disorder and the veteran denied ideas of reference and broadcasting. The veteran was preoccupied with his drug problem. He was also concerned about the health of his father and his own homelessness. Suicidal or homicidal ideations were denied. Cognitive functions were intact. Judgment and insight were limited. Upon hospitalization he was begun on a detoxification program. The examiner diagnosed alcohol abuse, episodic; cocaine abuse, continuous; rule out bipolar disorder, depressive type; antisocial traits; seizures; and back injury. Environmental stressors, including separation from his wife and homelessness, were assessed as moderate. In January 1993 the veteran underwent VA hospitalization including for alcohol and cocaine abuse treatment. The veteran complained of weakness, fatigue, and poor appetite for the prior three days. The veteran was observed to have increased tremulousness and to be ambulating with short, shuffling steps. A prior diagnosis of bipolar disorder and treatment with Haldol for the prior two weeks was noted. Emergency room treatment was noted to include Benadryl with good improvement but without resolution. The admitting examining physician diagnosed extrapyramidal reaction. Other diagnoses upon admission included alcohol and cocaine abuse; rule out dependent personality; history of seizures; and back injury. The veteran was also noted to be homeless and in the process of divorce. A history of multiple prior admissions for alcohol and cocaine abuse was noted. Prior suicide attempts were also noted. In the course of hospitalization the veteran admitted multiple suicide attempts in the past, discussed wife beating, and admitted attempting to kill his parents three times as a child. However, the examiner expressed serious doubts about the veteran's sincerity for his recounted history. The veteran had a history of a back injury in 1987 at work, with no work since that injury. He reported a past history of seizures but none for years. He reported that he had strained relations with his wife and children over his alcohol and cocaine abuse, and that his wife did not want him at home. The veteran was confused during the hospitalization, entering other patients rooms and behaving erratically, and was accordingly placed in protected seclusion. Upon evaluation on the third day of hospitalization, a bipolar disorder was noted, and the veteran was noted to be treated with Haldol, Lithium, and BuSpar. Objectively, the veteran was disheveled, foul smelling, in pajamas, cooperative, depressed, and with poor eye contact. Affect was blunted and speech labored and soft. He denied hallucinations or suicidal or homicidal ideations. He reported being overwhelmed by problems at home. He was oriented to person and place but not to time and date. Memory, concentration, judgment, and insight were poor. Upon re-evaluation on the fourth day, the veteran reacted emotionally to mention of his family and expressed suicidal ideations. On the fifth day he admitted to auditory and visual hallucinations, with voices instructing him to kill himself, and was begun on Lithium and Haldol. On the eighth day he admitted to being very apathetic toward improvement. Pressured speech symptomatic of mania was also noted during the hospitalization. However, upon questioning the veteran's wife admitted to no manic symptoms in the veteran. Examiners noted that the veteran may be confabulating symptoms, as for example, the veteran reported difficulty sleeping or no sleep throughout the hospitalization, though objective observations by the examining physician (the veteran appearing well-rested) and overnight nursing observation contradicted these reports. Some drug-seeking behavior was noted, and the veteran was noted to have adopted friends who had exhibited manipulative and drug-seeking behavior in the past. Upon hospitalization release the veteran was noted to be quite vulnerable to substance abuse relapse. The veteran conceded the same. Also in January 1993, the veteran received emergency admission to Brooks Memorial Hospital for complaints of nervousness, anxiousness, weakness, inability to sleep or eat, and termors in the extremities. The veteran denied any history of manic depression. The examiner diagnosed an emotional disorder, rule out medication reaction. The claims file contains records of further VA outpatient treatment in 1993 for alcohol, cocaine, and amphetamine abuse or dependence. Family and marital difficulties were emphasized. Diagnoses included rule out bipolar disorder, rule out chronic pain disorder, and personality disorder. Upon VA mental status examination for treatment in February 1993, the veteran reported a long history of anxiety problems and depression. He also reported a history of seizures and temper outbursts as a child, attempting to kill his parents at age nine, and attempting to burn his house down as a child multiple times. He also reported suffering from seizures in the mid 1970's, but reported that those had resolved. He reported a history of psychiatric hospitalizations related to suicide attempts. He reported being recently diagnosed as manic-depressive. The veteran walked with a limp and reported a history of worsening back problems and heart problems, though he denied any current follow-up for these conditions. He complained that at night he suffered from shakes, thoughts racing with an inability to stop his thinking, inability to sleep for a week to 10 days, and doing things nonstop. He reported problems with dissociation and concentration. He also had a feeling of walls closing in and ideas of reference, and hearing the voice of his mother. The veteran described a suicide plan involving jumping off a cliff, explaining that he was tired of crying and tired of his pain. The veteran was noted to be a poor historian and to have much difficulty with dates and other historic details. Judgment and insight were also poor. Also noted in the February 1993 VA examination report were histories of alcohol use to intoxication for twenty-one years, smoking opiates for ten years, smoking and inhaling cocaine for eight years, smoking amphetamines for four years, and using amphetamines for eight years. He reported that he began drinking wine daily at age 19, and always drank to get drunk. He reported that in 1975 he had seizures, attempted suicide, reduced his drinking, and had an explosive temper. He reported that he then began drinking heavily and experimenting with drugs, had two years of abstinence from 1987 to 1989, and then began drinking a case of beer per day after the death of his mother. He reported that he began smoking opium in 1983 after an injury, with heavy use from 1986 to 1989, and the last use of that drug in 1991. He reported that he began smoking and snorting cocaine in 1985, with last use in November 1992. He reported that he began using Amphetamines in 1989 and last used them in the summer of 1992. The veteran reported having urges to use drugs at times of chronic pain. He reported attempting to commit suicide by overdose on seven occasions, the first time in 1974 after his wife left, and thereafter at times of loss through the 1980's. He reported that currently chronic pain was causing depression and anxiety attacks. The examiner assessed that the information the veteran provided was not significantly distorted by misrepresentation or by an inability to understand. In March 1993 the veteran underwent a private psychiatric examination by D. J. Willis, M.D.. Noted was a long history of violent behavior following a closed-head injury during military service, with subsequent psychiatric treatment at a VA hospital in Buffalo, New York. The veteran reported that the injury resulted from a kick in the head by an expert in karate, and reported that he was in a coma for two days following the injury. The veteran, describing his condition, stated that he would "become violent and confused and beat people up." He also reported hearing voices that would tell him to kill people and to set fires. The veteran reported that the voices began approximately one year ago. The veteran reported that he stayed home much of the time out of fear he would act-out his impulses and hurt people. He also reported intense paranoia, particularly toward strangers. He reported that he would often try to kill himself in an impulsive manner, including multiple overdoses. He reported last using both alcohol and cocaine approximately six months ago. He reported that he was unable to recall the last time he had a seizure. The examiner found the veteran to be not altogether cooperative with the interview. The veteran admitted to thought broadcasting and a depressed mood, but denied feelings of hopelessness, helplessness, or worthlessness. While his affect was somewhat blunted, his speech was fluent without abnormality, and he was alert and oriented, well-nourished, well-developed, and well-groomed. He avoided eye contact. The examiner was not confident that the veteran was putting forth his best effort for cognitive testing. The veteran did not appear to be intoxicated. The examiner diagnosed organic personality disorder status post closed head injury, history of polysubstance abuse, and intermittent explosive disorder. Upon a New York State Department of Social Services survey, the veteran reported that he had been employed as an electrician from February 1992 to January 1993, but had ceased work due to his back, forgetfulness, and inability to climb. Upon a May 1993 private psychiatric assessment by D. J. Willis, M.D., the veteran was reportedly brought to the examination by friends because he suffered from a panic disorder and agoraphobia. The veteran's chief complaint was auditory hallucinations. He reported that as a child he was treated with Phenobarbital for hyperactivity and insomnia. He reported that from age 13 to 18 he was a Golden Gloves boxer and also got into many street fights and suffered many blows to the head. He reported that he was in the Army from 1973 to 1975 and was in charge of recruits at Fort Dix when he received a karate kick to the head which resulted in amnesia and seizure disorders. He added that he still had at least one seizure per week. He reported that he did not know what happened during the seizures, except that he would awake with a mouth full of blood. He reported that he received a medical discharge from service. He also reported that he went to a VA mental health clinic for approximately five years after service, but began drinking and dropped out of the clinic. He reported that he began having auditory hallucinations four to five years ago. He reported that these included instructions to kill his wife, her boyfriend, and himself, resulting in a psychiatric hospitalization. He also reported having a violent temper, with several assault charges. He reported giving up alcohol and cocaine eight months ago. He reportedly suffered from a panic disorder with agoraphobia since approximately November 1992, with VA hospitalization at that time. The examiner reviewed the veteran's trauma history and found that the veteran had in fact boxed from age 13 to age 19; that he had suffered a karate kick to the head in the Army, leading to a medical discharge; and that he was in an automobile accident approximately one year later wherein his head was jammed into the glove compartment and he suffered another concussion. A reported 10 suicide attempts were noted. He reportedly suffered from panic attacks when alone, with at least three panic attacks per week. The examiner noted that the veteran described classic panic attack symptomatology. The veteran also reportedly suffered from blackouts from alcohol consumption, and was frequently assaultive. He reported that on one occasion during a blackout he beat his wife to such an extent that she was hospitalized. He reportedly cleaned his house three times per day, which the examiner identified as elements of obsessive-compulsive disorder. Upon examination, the veteran was cooperative, relevant, and coherent. Thought content revealed a rapid-cycling type of illness. The veteran was oriented and his intelligence appeared aggregate normal. Judgment was satisfactory. The examiner diagnosed, in pertinent part, schizo-affective disorder, bipolar type; extremely severe panic disorder with agoraphobia; recurrent alcohol dependence and cocaine dependence, both in remission; and seizure disorder with etiology possibly post-traumatic. At another May 1993 private psychiatric assessment by K. J. Gorman, M.D., the veteran was treated for complaints of auditory hallucinations. The history was essentially the same as that noted by D. J. Willis, M.D, in May 1993, except the veteran reported that the karate kick to the head in service resulted in not only seizure disorders but also amnesia. Findings and diagnoses were also not materially different from those of D. J. Willis, M.D., in May 1993. The claims file contains records of ongoing treatment by Dr. Gorman in June and July, 1993. When seen in mid June, the veteran reported having at least three seizures in the prior week, and agreed to keep a log of seizures. He also reported some extreme nervousness in crowds and some hallucinations. The report from a session in late July, however, did not note any seizures. The claims file contains outpatient treatment records from Family Health Services from May 1993 to February 1996. A history of seizure disorder was noted. Outpatient treatment included for asthma and panic/anxiety disorder. From May 1993 to September 1993 the veteran was treated by E. Berke, M.D., apparently of Family Health Services. The physician noted the veteran's history of seizures, with reported treatment by a VA facility neurologist with stoppage of that treatment, with follow-up lost, with treatment with Tegretol restarted when seen for manic depression. The physician also noted that the veteran was presently being followed for his manic depression but not for seizures, and noted that the veteran questionably had a seizure one week prior, but noted that the veteran was very vague about his history. Neurological examination was within normal limits, with the veteran alert, oriented, and appropriate; cranial nerves two to twelve were grossly intact, and cerebellar functions were within normal limits. The examiner, in pertinent part, assessed only a history of seizures in May 1993. In September 1993 the veteran was hospitalized at Brooks Memorial Hospital for cardiac difficulties. While a seizure disorder was included among diagnoses in the hospitalization discharge summary, that diagnosis was not based on any objective findings reported within hospitalization records in the claims file. The veteran did report a history of a seizure disorder dating from being hit in the head while in service twenty years prior. He reported last having a seizure five months prior, and reported taking Tegretol on a chronic, permanent basis for treatment of the seizures. The claims file contains outpatient counseling session records from K. Gorman, M.D., a private psychiatrist, from September 1993 to July 1996. Treated symptoms or conditions included an involuntary movement disorder, auditory hallucinations with instructions to kill himself, impaired sleep, and other psychological difficulties, with control with psychopharmacology. Abstinence from abused substances in 1996 was noted. At a June 1994 RO personal hearing, the veteran testified that he was a Golden Gloves amateur boxer as a teenager, but that he wore protective head gear and was not injured when boxing, never suffered a blackout following a boxing match, and was never hospitalized as a result of a boxing incident. He testified that he had received medical authorization from a family doctor determining that he could box, and a medical check before each match. He testified that during his boxing period he was never treated with any type of medication for a blackout or seizure disorder. He testified that prior to service he was a good student and an athlete, and played on every team. In reference to a suicide attempt in 1974 noted in the veteran's record, the veteran explained that he had had a bad cold, had been taking cold medicine, and drank some vodka, with a resulting accidental overdose. He testified that in fact he never attempted to commit suicide prior to entry into service in 1975. He testified that prior to service entry he also was never treated by a psychiatrist and was never prescribed any medication for a nervous condition. He testified that in an automobile accident prior to service in August 1974 he suffered a broken nose and had required stitches on his nose and lip, with treatment at Mercy Hospital, but suffered no other injury during that accident, had no blackouts or seizure disorders or nervous conditions or panic disorders following that accident, and received no medication for a seizure disorder or blackouts following that accident. He added that following that accident he did not receive any treatment for head trauma. He testified that he entered service in 1975 because he was the only one in his family who had not entered service, adding that his father pressured him to enter the service. He added that when he entered the service his health was very good and he was not taking any type of medication for a nervous condition, blackouts, or seizures. He also testified that prior to service he was never diagnosed with any type of neurosis and never suffered from an inability to sleep or an inability to deal with authority. He testified that he only had normal headaches prior to service, for which he took no medication. He testified that he suffered an incident during his first week of service when he entered a confrontation with another enlisted man involving pushing and shoving, and he was suddenly kicked in the head, ending up in a corner and unable to get up. He testified that he was then very dizzy, could not keep his balance, and was bleeding from his left ear. He testified that he then broke down and could no longer function, and he blacked out. He testified that the next thing he remembered was talking to a sergeant in a mental health unit. He testified that following that incident in which he was kicked in the head, he could not sleep for a week. He added that after the incident he could no longer deal with sergeants or lieutenants. He testified that he had reported the incident in which he was kicked in the head to the sergeant in the mental health unit, but that the discussion was very informal, and he did not recall signing a statement. He testified that he was discharged from service because of his condition, and then returned to Buffalo, New York. He testified that after service upon his return to Buffalo, New York, he went to the VA hospital complaining of left ear pain, difficulty sleeping, shaking and trembling all over his body, and being upset. He added that after service separation and prior to going to the VA hospital he was experiencing blackouts for a day at a time about which he remembered nothing. He testified that during that hospitalization he was treated with Phenobarbital and Dilantin. He testified that a physician during that hospitalization had said that his left ear was "all black and blue" (hearing transcript ("ht"), p. 15) due to some sort of trauma. He testified that he experienced intermittent blackouts between 1975 and 1978, and decided to stop taking Dilantin and Phenobarbital in 1978. He testified that after 1978 his wife left him and he began drifting, drinking alcohol, and not doing anything. He testified that in the course of that drifting, while in Louisiana, he suffered a back injury with a herniated disc in his back, and then returned to Buffalo for treatment of his back disorder. He testified that he then again began receiving treatment for a seizure disorder, with prescriptions of Phenobarbital and Dilantin, adding that he continued that medication for some time thereafter. He testified that in 1983 and 1984 he received care for his seizure disorder from both a VA and a private physician. He testified that during that time he was also receiving treatment with Valium for a nervous condition. He testified that he was receiving treatment from Dr. Lall and Dr. Gorman, adding that Dr. Gorman was treating him with Benadryl, Thorazine, and Zantac. He testified that since 1975 he has continued until the present to experience blackouts and seizure disorders, with ongoing treatment. He testified that the seizures had remained essentially the same over the years, but that if he took his medicine four times per day like he was supposed to he would only have seizures perhaps once every two months, and they would not be as violent as they otherwise were. He testified that these seizures every two months were quite mild when he took his medication. He added, however, that he did not know how long the seizures lasted. He testified that when he had seizures he would lose consciousness, fall on the floor, thrash about, and when he would regain consciousness his mouth would be full of blood. However, he testified that if he started to tremble he would know a seizure was coming, and if he then took his medicine right away he was "pretty good" (ht, p. 42). He testified that he would otherwise lay down right away. He added that he experienced seizures at night sometimes, and they would be of such violence that he would be thrown out of bed. He added that the seizures were mostly at night. He testified that he also had an ongoing anxiety disorder or nervous disorder since 1975, with continued treatment. He testified that he could not function by himself and would get upset, so that he had to have someone with him, such as a sibling, when he went out, including to go shopping. He added that for meals and cleaning his apartment, he ate at his sister's house and his niece came to his apartment. He added that he had panic attacks, and would stay in his house for days at a time because he was afraid of people. He testified that he was currently receiving Social Security disability payments, with benefits received based on his seizure disorder, panic disorder, and schizophrenia. He testified that he had been receiving Social Security disability payments for one year. The claims file contains Brooks Memorial Hospital outpatient treatment records from 1996, with treatment for psychological and physiological conditions. However, the records of treatment contain no findings of seizure. In August 1996 at Family Health Service, the veteran was noted to have been treated adequately for control of seizures with prescribed Tegretol over a long period, but with recent recurrence of seizures and the veteran requesting reinstatement of stronger anticonvulsive therapy. A prior history of treatment with Phenobarbital and Dilantin was noted. Dilantin was prescribed. However, the records from Family Health Services included no testing for a seizure disorder. The veteran was briefly hospitalized at Brooks Memorial Hospital in September 1996 with an admitting diagnosis of Dilantin Toxicity and altered mental status. The veteran complained of weakness and dizziness, and was unable to ambulate without assistance, without falling. A history of prescribed doses at varying levels and higher levels of Dilantin intake were noted. A head CT revealed no gross structural abnormality, with no evidence of hemorrhage, no suspicious focal defect, and no mass of extra-axial fluid collection. There was also no midline shift. The CT examiner assessed a negative examination. The veteran was also hospitalized at Lake Shore Hospital in September 1996 for diagnosed severe, recurrent major depression with psychotic features; rule out schizoaffective disorder, depressive type; alcohol dependence; cocaine dependence; and personality disorder, not otherwise specified. A history of seizure disorder was noted. Multiple prior hospitalizations for substance abuse were noted. The veteran was ostensibly hospitalized based on suicide risk, with the veteran hearing voices telling him to kill himself and thinking of doing so with a knife, but instead telephoning for medical attention. The veteran was treated with Xanax for anxiety during the hospitalization, but he requested ever-increasing quantities of the drug. (The veteran was advised of Xanax's addictive potential and the dosage was lowered. A past history was noted of the veteran self-medicating for anxiety with increasing doses of Xanax.) He was also medically treated for depression and sleep impairment. During that September 1996 Lake Shore hospitalization, the veteran was neurologically evaluated for seizures. The veteran reported a history of a karate kick to the head in 1975 with seizures diagnosed thereafter. He reported that the kick caused him to lose consciousness and caused blood to come from his ears. He reported being treated first with Tegretol and then with Dilantin, with stabilization apparently achieved with Dilantin. He reported that he had had no seizures for approximately three years until approximately three months ago, when they began again. He reported having his last seizures approximately two days prior to admission, and again at approximately 10:00 a.m. on the morning of the examination. The veteran reported never smoking and quitting drinking four years ago. A family history was positive for nervous disorders and seizures. The veteran was currently medicated with Dilantin. Objectively, the veteran was alert and oriented but appeared slightly depressed. Cranial nerves were intact except for a slight ptosis, slightly more prominent on the left. Cerebellar function was assessed as overall intact, and all motor function was 5/5. Sensation was intact except on the lateral aspect of the right leg. Seizures were assessed. Also noted were general weakness, twitching, and mood changes, assessed as most likely due to low Dilantin levels. In an October 1996 response to an RO query for additional service medical records, the Chief, Army Reference Branch, National Personnel Records Center (NPRC), informed that a diligent search was conducted but no additional records were found. In particular, the Chief informed that a requested continuation sheet to a chronological record of medical care dated March 21, 1975, could not be found and must be assumed to have been lost. At a May 1997 VA psychiatric examination, the examiner noted that he had thoroughly reviewed the claims file. The examiner noted that thought the veteran was oriented times three he was very evasive and guarded when answering questions. He frequently stated that he did not remember or that an event never happened. He reported that all his problems began following his getting kicked in the head in service. He claimed that he suffered from command hallucinations that told him to harm himself, and that he occasionally became depressed. He denied current alcohol and drug abuse. He reported that he was unsure whether he was currently suffering from any seizures. The veteran reported currently taking Dilantin, Tegretol, Risperidone, Moban, Amantadine, and other medications. However, the examiner noted that most of the information given by the veteran was not accurate. Notably, he reported being in the Army 68 days and being in a coma following being struck in the head. The examiner informed that because of the unreliability of the veteran the examiner had to rely on the record rather than the veteran. The examiner noted a childhood history of treatment with Phenobarbital for hyperactivity and insomnia, and a history as a Golden Gloves boxer from age 13 to 18, with many street fights also during that time and many blows to the head. The veteran denied any recollection of those incidents. The examiner also noted a history of an auto accident in August 1974 and a suicide attempt in December 1974. The examiner noted that the veteran was apparently discharged from service after 22 days due to behavior difficulties and inability to cope with the pressures of service. The examiner noted that there was a history of depression and suicide attempt prior to the veteran's entry into the Army. The examiner noted that after service separation on April 4, 1975, the veteran underwent VA hospitalization from April 16, 1975, to April 24, 1975, and during that hospitalization reported suffering a head injury in service and complained of anxiety, with difficulty dealing with authority since that inservice injury. The remainder of the veteran's prior medical history was also noted. The examiner concluded that it was almost impossible, in light of the history of multiple head traumas prior to service and depression and a suicide attempt prior to service, that all the veteran's problems stemmed from a single head injury in service. The examiner diagnosed major depression with psychotic features; history of multiple substance abuse; personality disorder not otherwise specified; and history of seizure disorder. In responding to questions posed by the Board, the current diagnosis of major depression with psychotic features delineated a current diagnosis of an acquired psychiatric disorder. In response to a question as to whether a psychiatric disorder other than a personality disorder was present during service, he stated that the veteran had anxiety and depression during service, which had been present before service. In response to a question as to whether any chronic acquired psychiatric disorder found to be present in service, clearly and unmistakably pre-existed service, he stated that depression "probably" existed prior to service but that it was "pure conjecture" and that he could not "definitely" say that depression was present before service. In response to a question as to whether any chronic acquired psychiatric disorder was due to a reported pre-service head injury in August 1974 or was due to a reported head injury in service, he did not provide an intelligible response. At a May 1997 VA neurological examination, the veteran was examined with normal findings. The examiner assessed unremarkable neurological examination with no focal deficits. The examiner added that the veteran's reported seizures were idiopathic, and that the relationship to a reported head trauma in service was uncertain. At a December 1997 VA neurological examination, the veteran reported a history of being kicked in the head in service 20 years prior, losing consciousness for an undetermined period of time, and losing all memory of the day prior and several days after being hit on the head. He also reported having a seizure a couple of hours after that kick in the head. He stated that he had described the episode - consisting of shaking all over, losing consciousness, and awakening with blood and foam in his mouth - to physicians later, and they had identified it as a seizure. He reported currently having one or two seizures per day, and reported frequently wetting his pants during seizures, though not defecating. He also reported that he did not drive. Objectively, the veteran's examination was entirely normal, as were his cranial nerves and mental status, as were motor and sensory examinations. Deep tendon reflexes were 2+ and toes were downgoing. The veteran was noted to be taking Tegretol and Dilantin for seizures. The examiner noted that there was apparently no evidence of seizure disorder other than the veteran's report, and that the veteran had reported that no one had seen his seizure episodes. The examiner concluded that it was possible that the veteran suffered from a seizure disorder and that the disorder began in service, but there was no proof other than the veteran's word. The examiner added that while a seizure disorder may begin following a head injury, in this case there was no documentation of either the inservice head injury or the initial seizures reported by the veteran. The examiner also concluded that it was likely that if the veteran had such frequent seizures as he reported, they would have reached medical attention because of the inherent interference they would have caused with the veteran's performance. In an October 1998 addendum to the December 1997 VA examination, the examiner noted that an electroencephalogram had been performed and was normal. The examiner noted, however, that a normal electroencephalogram did not rule out the possibility of seizures, and the reading may be normal when an epileptic is not having an active seizure. A CAT scan was also normal, but the examiner stated this also did not confirm or refute the possibility of a seizure disorder. 2. Analysis Initially, the Board finds the veteran's claims well grounded pursuant to 38 U.S.C.A. § 5107 (a) (West 1991) in that his claims are plausible. Murphy v. Derwinski, 1 Vet.App. 78 (1990). The veteran has presented medical records documenting a possible psychiatric disorder and a possible seizure disorder, with possible development or aggravation during his period of service. Once it has been determined that the claims are well grounded, the VA has a statutory duty to assist the veteran in the development of evidence pertinent to the claims. 38 U.S.C.A. § 5107. The Board is satisfied that the RO has made all reasonable efforts to obtain all available evidence pertinent to the claims and that proper appellate development, including appropriate notice to the veteran, has been made. The Board also notes that medical records relied upon for a Social Security disability determination were included in the record. The Board is satisfied that all available evidence necessary for an equitable disposition of the appeal has been obtained. The Board therefore finds that the duty to assist has been met. 2. a. Service Connection for a Psychiatric Disorder The existence of an acquired psychiatric disorder was not noted on the pre-enlistment examination by specific diagnosis or by a more generalized clinical notation. As such the presumption of soundness at enlistment applies. 38 U.S.C.A. §§ 1111, 1137 (West 1991). The presumption of soundness at enlistment may be rebutted by clear and unmistakable evidence showing the pre-service existence of an acquired psychiatric disorder. Such evidence may consist of pre-service clinical records reflecting a psychiatric diagnosis or a medical opinion that a psychiatric disorder present during service clearly and unmistakably pre-existed service. Recorded clinical data in service medical records or any other medical records, alone, will not rebut the presumption of soundness at enlistment. Crowe v. Brown, 7 Vet. App. 238 (1995). The current psychiatric diagnosis is that of major depression with psychotic features. Although the veteran was discharged from service for what was reported to be a character and behavior disorder, the veteran was also assessed during service as moderately depressed and severely anxious. His psychiatric disorder has been assessed as involving symptoms of anxiety and depression ever since discharge from service. On the May 1997 VA psychiatric examination the examiner concluded that the veteran had anxiety and depression during service. This is considered to represent an acquired psychiatric disorder. The examiner was unable to state that an acquired psychiatric disorder manifest by anxiety, depression, or any other symptoms, clearly and unmistakably existed prior to service. The RO has not obtained pre- service clinical records reflecting the existence of an acquired psychiatric disorder. The presumption of soundness at enlistment with regard to the pre-service existence of an acquired psychiatric disorder has not been rebutted by clear and unmistakable evidence. The currently diagnosed psychiatric disorder is found to have its onset in service. 2. b. Service Connection for a Seizure Disorder Regarding the veteran's claim for service connection for a seizure disorder, the Board notes that while the veteran has been treated over the years with some medications typically prescribed for seizure disorders, the veteran has, by his own admission at a December 1997 VA examination, never been observed experiencing a seizure. This non-observation comes in spite of recent once-to-twice daily frequency of seizures, as also reported at the December 1997 VA examination, with such reported significant loss of bodily controls during his reported seizures as to result in pants wetting. Medical examiners who have diagnosed a seizure disorder or a history of seizure disorder have based this upon either prior medical diagnoses and treatments for seizures or upon the veteran's account of prior seizures. The veteran's history of a seizure disorder has been inconsistent. The Board notes that the veteran had reported a history to J. J. Maurizi, M.D., as reflected in that physician's January 1990 medical report, of having suffered multiple grand mal seizures in service following an injury, with subsequent discharge from service due to the seizure disorder. Other histories provided by the veteran of seizures beginning in service report no grand mal seizures, but similarly contradict the veteran's service record. The service record makes no mention of seizures and shows that the veteran was separated from service essentially on the basis of mental unfitness for service. Further, EEGs post service have been within the normal range or have otherwise not verified the presence of a seizure disorder. Other testing of the veteran's brain functioning has never positively identified a seizure disorder. The December 1997 VA examiner, while noting that it was possible that the veteran suffered from a seizure disorder that had never been observed by anyone, concluded that there was no medical evidence conclusive of the presence of a seizure disorder, and that it was unlikely that the veteran suffered from a seizure disorder for years with his reported recent daily or twice-daily seizures and observable effects such as pants wetting, that had never been observed by anyone. While the veteran has reported a long history of blackouts dating from service, the veteran also has a long medical history of abuse of alcohol and street drugs, including cocaine, and medical treatments including VA hospitalizations, for these abuses. Some medical records have noted a history of alcohol-related blackouts. While the veteran may sincerely believe that he suffers from seizures, there are clearly other medical bases within the record, including in particular ongoing alcohol and drug abuse, for the veteran's reports of symptoms such as loss of consciousness, loss of memory of time intervals, and blackouts. The Board does not find plausible the veteran's carefully described symptoms of his seizure attacks as reported in hearing testimony in June 1994, since he also testified that he has no memory of his seizure events and he stated at his December 1997 VA examination for seizure disorders that no one has ever witnessed him having a seizure. There is no medical evidence based on objective findings rather than reports by the veteran, to support a conclusion that the veteran has ever suffered from a seizure disorder, as such. April 1989 testing, observation and monitoring for epilepsy at the Millard Fillmore Hospital resulted in a diagnosis that a seizure disorder was ruled out. The claims file contains records from numerous hospitalizations of the veteran over many years for multiple medical conditions, including many hospitalizations for substance abuse or suicide attempts, with all the associated monitoring during these hospitalizations, yet with no medical report even once identifying an observed seizure. Because the veteran has presented diagnoses of a seizure disorder, including possibly as related to a reported prior trauma in service, the veteran's claim for service connection for a seizure disorder is well grounded. Caluza; Tidwell. However, in light of the apparent unreliability of the veteran's account of his history of seizures, and the absence of any diagnosis of a seizure disorder based on objective medical evidence of seizures or other independent corroborating evidence, the Board must conclude that the preponderance of the evidence is against the presence of a seizure disorder in service and is against the presence of a seizure disorder at the current time. Accordingly, the claim for service connection for a seizure disorder must be denied. ORDER 1. Service connection for a psychiatric disorder is granted. 2. Service connection for a seizure disorder is denied. BRUCE E. HYMAN Member, Board of Veterans' Appeals