Citation Nr: 0006266 Decision Date: 03/08/00 Archive Date: 03/17/00 DOCKET NO. 94-47 241 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a psychiatric disability. REPRESENTATION Appellant represented by: Gwendolyn D. Cosey, Attorney ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The veteran had active service from May 1952 to January 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1994 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied a request to reopen the veteran's claim of entitlement to service connection for a psychiatric disability. In a May 1997 Board decision, it was concluded that new and material evidence had been submitted to reopen the veteran's claim of entitlement to service connection for a psychiatric disability. The Board remanded the veteran's claim for de novo review. In a May 1999 decision, the RO again denied the claim of entitlement to service connection for a psychiatric disability, and the veteran's claim was returned to the Board in October 1999. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's claim has been secured by the RO. 2. The medical evidence and opinions of record, when read as whole, place the evidence as to whether the veteran first manifested a current chronic psychiatric disability in service in equipoise. CONCLUSION OF LAW Resolving doubt in the veteran's favor, a chronic psychiatric disability was incurred during active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran has claimed entitlement to service connection for a psychiatric disability. Service connection is warranted for a chronic disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. If a disorder is not shown to be chronic during service, continuity of symptomatology after service is required to establish that a disorder is chronic. 38 C.F.R. § 3.303. When a disease is first diagnosed after service, service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during the veteran's service. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). VA regulations provide that congenital or developmental defects, defined as including personality disorders, are excluded from the types of diseases or injuries for which service connection is authorized. 38 C.F.R. § 3.303(c); see Winn v. Brown, 8 Vet. App. 510, 515-6 (1996). Thus, service connection for a personality disorder, even if first manifested in service, is not authorized. Factual Background The veteran's service medical records reflect that no pre- existing diseases or defects, other than scars, were noted on service induction examination in May 1952. In December 1953, the veteran was taken to the dispensary because he was "irrational." An alcoholic odor was noted. He was hospitalized with an admitting diagnosis of psychosis, undetermined type. He was excited and confused and experiencing visual hallucinations. About eight hours after admission, he became free of mental confusion. He was discharged about 10 days later. The final diagnosis was, "observation, psychiatric." In July 1955, the veteran was hospitalized, with a diagnosis of passive-aggressive reaction, after becoming belligerent, hostile, uncooperative, and destructive following a social event at which the veteran had been drinking. During the hospitalization, the veteran's affect returned to normal, he was cooperative, and his emotional responses were appropriate, but he remained nervous and tense. It was noted that the veteran had a very low tolerance for alcohol. The final diagnosis was aggressive reaction. In December 1955, the veteran was admitted by his own request after he hit a friend while intoxicated. There was no psychosis. The veteran was advised to refrain from drinking alcohol, as he was unable to control his aggressiveness when drinking. Treatment notes dated in August 1956 reflect that the veteran had been drinking again. He had gotten married, but the marriage was failing because of his drinking. The examiner noted that it was "extremely difficult" for the veteran to refrain from use of alcohol. The examiner noted that "[m]any times he feels depressed, worried, irritable, or mad without knowing why. When he is in these moods, he feels a strong urge to drink in order to get relief from the . . . unpleasant feelings." The examiner concluded that the veteran was emotionally unstable and aggressive. He assigned a diagnosis of character disorder, aggressive reaction, manifested by emotional instability, alcoholism, accompanied by aggressive behavior and followed by amnesia. The veteran remained hospitalized until late August 1956. In early September 1956, the veteran was admitted following a suicide gesture. The veteran slashed his wrists with a broken bottle after drinking heavily. By the day following admission, the veteran was sober, was not anxious or despondent, there was no evidence of active neurotic or psychotic thought process, judgment was impulsive and immature. The final diagnosis was simple drunkenness and emotional instability reaction, chronic, severe, manifested by outbursts of aggressive behavior, continuous over- indulgence in alcohol, and impulsive and immature judgment. Two days after hospital discharge, the veteran was again hospitalized. He had been drinking and made superficial lacerations on his wrists. The examiner concluded that his condition "will not respond to any type of rehabilitation, discipline, or therapeutic measures." The final diagnosis was emotional instability reaction, chronic, severe. Following his service discharge in January 1957, the veteran was admitted to the Miami Sanitarium in October 1957, following a suicide attempt. The veteran slashed his throat and led a vehicular police chase while intoxicated. His admission was ordered by a judge, who found him incompetent. On admission, it was thought the veteran was suffering from a psychotic reaction. The veteran was confused, upset, and depressed. The report of this hospitalization reflects that, although the veteran's psychosis disappeared, psychiatric disability continued. Treatment with electrocoma (now known as electroconvulsive therapy) was initiated, and the veteran had 9 such treatments. Psychological testing revealed passive-aggressive personality disorder. The veteran remained upset, confused, and depressed throughout his one- month hospitalization at this facility. The final diagnosis was schizophrenic depressive psychosis. The veteran was transferred to a public, state mental hospital in November 1957, and remained hospitalized there until May 1958. The admission diagnosis was neurotic depression. In the controlled environment of the hospital, he recovered from his depressive state over the six-month period of his hospitalization. The final diagnosis was depressive reaction. In August 1958, the veteran underwent VA hospitalization for observation to determine whether he had a psychosis, a personality disorder, or chronic alcoholism. The examiner who conducted psychological evaluation in August 1958 concluded that the veteran avoided expression of "unstable emotionality" through rigid intellectual controls, which crumbled rapidly with use of alcohol, followed by pathological intoxication and outbursts of violent behavior. The veteran was emotionally withdrawn, unable to establish close relationships, and used ruminations "not well related to reality" to fill the void in his life. The examiner concluded that the veteran had an unstable personality with compulsive traits and schizoid tendencies, and was prone to pathological intoxication. The veteran complained of feeling nervous. The final diagnosis was emotionally unstable personality, "complicated by occasional alcoholic overindulgence, at which time he becomes psychotic." The examiner concluded that when the veteran recovered from episodes of overindulgence in alcohol, he had "more or less normal personality." In 1963, the veteran was hospitalized for complaints of depression. The discharge summary of a private hospitalization from December 1968 to February 1969 reflects that he was admitted following "agitated depression" and threats of suicide. Electroconvulsive therapy was provided. The final diagnoses included depressive reaction, psychoneurotic, recurrent. An April 1971 private psychiatric admission history reflects that the veteran had made multiple suicide gestures and attempts, including drug overdoses, and had been arrested more than 60 times for public intoxication. The examiner concluded that use of alcohol was associated with depression and anxiety. The veteran was admitted for private hospitalization in May 1973 because of acute depression and suicide attempts, and the diagnosis was acute depressive reaction. The veteran was admitted to the same hospital, acutely anxious and depressed and withdrawn in November 1973. The diagnostic summary of April 1974 to May 1974 private hospitalization reflects that the reasons precipitating admission were recurrent depression, suicidal gestures, anxiety, and alcohol. On psychological evaluation during this hospitalization, the veteran was anxious, depressed, fearful, withdrawn. The examiner concluded that the veteran had obsessive-compulsive defense mechanisms as primary mode of functioning, using depression and withdrawal to guard against his anger and aggression. The examiner further stated that "this neurotic mode of adjustment appears to have underlying psychotic mechanisms which break down when his defense mechanisms become ineffective, as with stress or under the dissociative influence of alcohol." The summary of VA hospitalization from April 1982 to July 1982 reflects that the veteran was admitted for treatment of trauma following a motorcycle accident. Manic depressive syndrome and alcoholism were also diagnosed. On VA examination in September 1982, the veteran was anxious, jittery, quivering, almost agitated, but was also depressed and expressed death wishes. Intellectual function appeared impaired by anxiety. The examiner questioned whether the veteran might have a manic depressive illness. On VA hospitalization in June 1983, the final diagnosis was bipolar disorder, depressed type. In a December 1983 private psychological evaluation, the veteran reported he had a problem with alcohol and drugs, having a low tolerance for alcohol and a high tolerance for drugs. He reported attempting a substance abuse program, but stated that when his sobered up, his psychiatric problems emerged and he was transferred to a psychiatric treatment program. The results of psychological testing were consistent with a diagnosis of a psychotic level of depression, and the examiner opined that "it seems likely that this is what has been happening all along." The examiner also questioned the frequent references to alcoholism, noting that the veteran had none of the predictable physical manifestations of alcohol abuse, in particular, he did not, for example, have any cirrhosis. VA outpatient and inpatient treatment records from 1983 to the present reflect that the veteran has received continuing VA treatment, with some interruptions, primarily under the diagnoses of bipolar disorder, major depression, or generalized anxiety disorder. In a June 1994 statement, the veteran's treating VA psychiatrist related that the veteran had a chronic psychiatric history, and notes the 1983 VA diagnosis of bipolar disorder. The treating physician opined that "[t]here is no question that this vet[eran] has been suffering from this psychiatric disorder the past 40+ years." In the report of an April 1998 VA examination, that same psychiatrist reported diagnoses which included bipolar II disorder, depressed, and stated that, given the veteran's history, it was difficult in this case to tell whether the abusive use of alcohol and marijuana always existed along with a psychiatric disorder. The examiner noted that, initially, the veteran's psychiatric symptomatology and hospitalizations occurred when the veteran was drinking alcohol or using drugs. His history reflected that he was better without the affect or alcohol or drugs, which were known to produce depression as well as psychotic symptoms and personality changes. The examiner further noted that, although the veteran's mood and behavior improved when alcohol and drugs were removed, overall the depression had persisted. In April 1999 the VA psychiatrist again examined the veteran. The diagnoses again included bipolar II disorder, depressed. The examiner observed that there was substantial evidence that the veteran's history was quite consistent with the expected findings and diagnoses given from 1953 to 1994. After noting that mental illnesses were caused by chemical imbalance in the brain., she stated that mood-altering (psychoactive) substances affected the chemical balance of the brain by changing levels of various neurotransmitters and that addictive disorders could cause psychiatric symptoms that present like psychiatric disorders. The VA psychiatrist related that it was extremely difficult to distinguish between those symptoms brought on by mental illness and those brought on by psychoactive substance use. After noting that alcohol could depress the central nervous system directly, producing psychosis, and causing individuals to exhibit out-of-control behavior; it was indicated that an accurate evaluation could only be made when detoxification was complete. The examiner then stated that examiners had determined that the veteran's psychiatric symptoms disappeared when he was no longer under the influence of alcohol. In a May 1999 report of contact, it was reported that the examiner declined to opine as to whether it was as at least as likely as not that the veteran's mental disorder was manifested within a year of his discharge from service. She stated that she had no was of altering her opinion that the veteran's alcohol use was the behavioral influence during the veteran's first year after service discharge and to 1974. Analysis The above summary of the veteran's lengthy history of psychiatric inpatient and outpatient treatment reflects numerous diagnoses and widely divergent medical opinions as to the etiology of the veteran's symptoms. During the period of the veteran's service and within one year after his service discharge, the veteran's diagnoses at hospital discharge, and after alcohol detoxification, included passive-aggressive reaction, character disorder, recurrent neurotic aggressive behavior, aggressive reaction, emotional instability reaction, chronic, passive-aggressive personality disorder, neurotic depression, depressive reaction, schizophrenic depressive psychosis, pathological intoxication, simple drunkenness, and unstable personality. Over many years of continued inpatient and outpatient psychiatric treatment, the veteran amassed further diagnoses. These diagnoses continued to vary. In 1994, the veteran's treating VA physician opined, on the basis of history as provided by the veteran, that he had been suffering "from this psychiatric disorder" for over 40 years. The physician did not assign a specific diagnosis, but did reference the assignment of a diagnosis of bipolar disorder in 1983 by the veteran's then-treating VA physician. Thereafter, in 1998, the same examiner, again noting that the veteran's history, referenced the available service medical records and post-service treatment records, observed that it was difficult to determine whether the veteran had always had a psychiatric disorder existing with abusive use of alcohol and drugs, and noted that the veteran continued to have a psychiatric disorder when abstinent from alcohol and drugs. This medical opinion suggests that the veteran had a continuous and chronic psychiatric disorder which was first manifested in service, although alcohol exacerbated psychiatric disability at that time. The same examiner, in 1999, noted the present medical understanding that mental illnesses are caused by chemical imbalance in the brain. This statement appears to indicate that the veteran's current chemical imbalance, resulting in his current psychiatric disorder, was present when manifestations of a psychiatric nature, now known to be due to a chemical imbalance, were first noted in service. However, the examiner further states that the veteran's psychotic symptoms could be result of alcohol or drug use, and states that treatment records which indicate that the veteran's psychiatric symptoms disappeared when the influence of alcohol disappeared establish that the veteran's psychiatric disability was due to psychoactive substances. It is unclear whether or not the psychiatric manifestations which developed after the veteran's use of alcohol were the result of an underlying psychiatric disability or merely an acute reaction to alcohol. The service medical records and treatment records proximate to service reflect that the veteran had very low tolerance for alcohol, and include diagnoses of pathological reaction to alcohol. The Board notes the examiner's conclusion that the veteran's psychiatric symptoms disappeared as the effects of alcohol disappeared. However, the overall factual evidence of record does not completely support this conclusion by the examiner. The Board also notes that, although a diagnosis of simple drunkenness was assigned in service, and numerous diagnoses of alcoholism, chronic alcohol abuse, or overindulgence in alcohol, and the like, were assigned over the years, the medical evidence as to whether the veteran was addicted to alcohol is somewhat contradictory. As the examiner who conducted a private evaluation in December 1983 noted, despite the numerous diagnoses related to alcohol use, there had been no evidence of any physical manifestation of alcohol abuse, such as cirrhosis of the liver. The Board notes that there has been no clinical evidence of such findings or diagnoses since that observation in 1983. Moreover, less than 9 months after the veteran's service discharge, he was admitted for period of psychiatric hospitalization that continued uninterrupted for nearly eight months. The report available for that hospitalization reflects that the veteran was treated for severe depression, including electroconvulsive therapy. The records reflect a judgment that, in the controlled environment of hospitalization, the veteran's depression gradually cleared. However, since this hospitalization extended for nearly eight months, the facts contradict a finding that the veteran returned to a normal baseline of functioning when not under influence of alcohol. Rather, the medical evidence of record establishing that the veteran remained depressed for many months appears to contradict such a finding. While in April 1999 the VA psychiatrist indicated that examiners had determined that the veteran's psychiatric symptoms disappeared when he was no longer under the influence of alcohol and she ultimately concluded that alcohol was the veteran's behavioral influence prior to 1974, the same examiner in June 1994 had stated that there was no question that the veteran had been suffering from a psychiatric disorder for more than 40 years and in April 1998 noted that the veteran's depression persisted without alcohol and drugs. If the examiner intended the opinion to reflect, in essence, that the chemical imbalance the veteran has currently has been present continuously and chronically since service, but that, prior to 1974, the imbalance was only manifested so severely as to require treatment when exacerbated by use of alcohol or drugs, the opinion weighs in favor of the veteran's claim. In summary, the evidence in this case appears to be essentially in equipoise. The examiner's statements include some opinions which appear to favor a finding that it is more likely than not that the veteran's current psychiatric disorder, however diagnosed, has been chronic and continuous since service. However, some portions of the examiner's opinions appear to weigh against the veteran's claim. Moreover, it is not clear that the portions of the examiner's opinion which weigh against the veteran's claim are entirely consistent with the clinical evidence of record. The Board finds that the evidence of record is not persuasive in favor of the veteran's claim, but the preponderance of the evidence is not against the veteran's claim. Resolving reasonable doubt in the veteran's favor, as mandated in such circumstances under 38 U.S.C.A. § 5107(b), the Board finds that evidence warrants a finding that the veteran has a current psychiatric disability, variously diagnosed, which was first manifested in service and has been chronic and continuous since that time. Accordingly, a grant of service connection for a psychiatric disability is in order. ORDER Entitlement to service connection for a psychiatric disability is granted. The appeal is allowed, subject to the law and regulations governing the payment of monetary benefits. HILARY L. GOODMAN Acting Member, Board of Veterans' Appeals