BVA9505170 DOCKET NO. 92-07 175 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Hudson, Associate Counsel INTRODUCTION The veteran had active service from September 1962 to September 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a regional office (RO) rating decision of September 1991. The case was remanded in October 1992 and again in October 1994 for additional development. The requested development in October 1994 included the issue of entitlement to service connection for post-traumatic stress disorder (PTSD), raised by the veteran's representative. However, subsequent to the remand, in correspondence received in November 1994 and again in December 1994, the veteran stated he did not wish to be examined for PTSD, nor to file a claim for PTSD. Consequently, that issue has been withdrawn by the veteran. CONTENTIONS OF APPELLANT ON APPEAL The veteran essentially contends that his currently diagnosed bipolar disorder had its onset while he was on active duty. He maintains that the stresses in service led to the development of the disorder. He has related episodes which he states occurred in service, and which he contends represent "manic" episodes of his psychiatric disorder. This caused problems for him in service, and, although he was able to complete his tour of duty, it was with difficulty. His platoon sergeant urged him to take a "Section 8" discharge, but he resisted. Subsequent to service, he has had difficulty holding a job, and he is unable to tolerate any stress. He had 8 jobs his first year out of service. From 1967 to 1975, he was in the Merchant Marine, which was somewhat erratic employment. In addition, it took him 9 years to attain a two-year community college degree. He believes that his psychiatric disability gradually worsened after service, to the point where he required hospitalization in 1976. 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. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the originating agency. 2. Service medical records are unavailable. 3. An acquired psychiatric disorder, diagnosed at the time as schizophrenia, was first demonstrated in 1976, with an approximate two year history of pertinent symptomatology noted at that time. 4. Currently diagnosed bipolar disorder was first demonstrated many years after service, and is unrelated to any events therein. CONCLUSION OF LAW An acquired psychiatric disorder was not incurred in or aggravated by active service, and psychosis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, we find that the appellant's claim is well-grounded; that is, it is plausible. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78 (1991). The relevant facts have been properly developed, and, accordingly, the statutory obligation of the Department of Veterans Affairs (VA) to assist in the development of the appellant's claim has been satisfied. Id. Background In this case, there are no service medical records available except for a clinical record cover sheet showing the veteran was hospitalized for one day in February 1963 for a flu like syndrome. The veteran's Form DD 214 showed he received an honorable discharge. During his nearly three years of active duty, he was promoted from E-1 (Private) to E-4 (Specialist 4), with the final promotion occurring in April 1964. The first documentation of psychiatric treatment following service was a letter from D. Short, M.D., of the U.S. Public Health Service Hospital, undated but apparently written in July or August of 1976, to a VA hospital, stating that he had treated the veteran periodically for two years. In the spring of 1975, the veteran had experienced an episode manifested by hyperactivity, flight of ideas and difficulty organizing himself. He responded well to medication, and recovered in about June of that year. Since then he had completed two quarters at a community college. He had worked at odd jobs or been on unemployment as a source of funds. He had returned to the clinic in the first part of June with recurrence of anxiety, hyperactivity, lack of sleep, flight of ideas, and inability to organize sufficiently to complete his final quarter of school. His symptoms were not controlled by medication without excessive side effects. Dr. Short recommended that the veteran be hospitalized. According to a justification for admission to a VA hospital dated August 3, 1976, the veteran had been functioning fairly well as a merchant seaman until about 1-1/2 years earlier. Since that time he had been unemployed and seeing Dr. Short. The veteran described "problems all [his] life - a couple of nervous breakdowns." He had never been hospitalized but was currently on psychotropic medication. He described cycles of hyperactivity, with poor impulse control, minor brushes with the law, and an inability to organize or cope with the activities of daily life. These cycles were followed by periods of depression. Currently, he had a flattened affect, some flight of ideas, and hostile feelings toward relatives. The veteran was hospitalized from August to September 1976 in the VA hospital, with a final diagnosis of schizophrenia, schizo- affective type. According to the hospital summary, his primary problem was a gradual loss of energy and motivation in attending his courses at the community college in Seattle. He stated he had functioned quite well until the spring of 1975, when he became somewhat disorganized and unable to complete his tasks. Currently, he felt unmotivated, with an identity crisis and anger at his family. He appeared to have faulty perceptions and his affect was inappropriate. He was placed on antipsychotic medication and responded well to this and therapy. He was to be followed as an outpatient. The veteran's first claim for benefits based on disability (pension) was filed with the VA in August 1976, at which time he stated he had a mental disability which had begun in August 1976. Eleven days after he was discharged, he was again hospitalized, where he remained until May 1977. It was noted that following his discharge, he had become increasingly anxious and withdrawn, sleeping up to 18 hours per day. In March 1977 his medication was discontinued with good results, and at the time of discharge, he had made remarkable improvement, and was energetic, outgoing and optimistic. A psychiatric examination in July 1978 revealed a history of auditory hallucinations "eight to ten years ago." He currently complained of occasional feelings that he would die, which appeared to correlate with diffuse anxiety. The veteran next sought treatment at the VA in January 1979, in a hypomanic state complicated by alcohol intoxication with poor impulse control and poor judgment. Records show his continued outpatient treatment in the mental hygiene clinic. In June 1988, a VA psychologist prepared a case summary which outlined a "13+" year history of the veteran's manic depressive illness and social maladjustment. He had been hospitalized twice in 1975 and 1976 following a manic episode and psychotic break in the spring of 1975. He was discharged to follow-up care, and had been seen approximately weekly in the mental health clinic for group therapy and medication management for the last 9 years. He had attempted to work, but had been unable to keep a job. A breakdown following his enrollment in a long-haul truck driving school was described. He returned to Seattle and had not worked since. He was noted to be compliant with medication and treatment, but unemployable. The veteran first filed a claim for service connection for a psychiatric disorder in March 1991. In March 1991, the same psychologist wrote that the veteran had asked about the origin an etiology of his illness, considering the variety of diagnoses he had had over time. In spite of the fact that his military records had been destroyed in a fire, the letters and journals kept by the veteran during his military duty were a clear indication of the active presence of his bipolar affective disorder during his basic training and subsequent duty. Without understanding the meaning of what was occurring he described many episodes of clearly manic behavior while on active duty. These manic episodes included confusion, pressure, and acceleration in his thinking with instances of grandiose delusions. His speech was pressured, incoherent, and inappropriately idiosyncratic. He described impulsive, hyperactive behavior with grandiosity and belligerence. The episodes were clearly visible to those around the veteran and resulted on several occasions in disciplinary action or referral to the medical service. He documented extended periods of several days without sleep, during which times his fellow soldiers and superiors described him as "crazy." At one point he was offered a psychiatric medical discharge, which he refused. Subsequent to service, he was predictably unable to work productively, having eight short-term jobs that first year. He avoided treatment by staying largely by himself. While he was in the Merchant Marine, other seamen often covered for him He finally was treated in 1973, when the long standing nature of his manic depressive illness was recognized and he was hospitalized. He had been in some form of treatment nearly continuously since that time. It thus appeared quite clear that the veteran's initial episodes of manic behavior and bipolar pattern occurred on active duty, and persisted undiagnosed for some time after that. The veteran presented testimony at a hearing in February 1992. He testified regarding several instances of "manic" behavior on his part in service, including his being isolated during bayonet training due to his overly enthusiastic behavior; odd speech and overreaction while on guard duty; an instance in which he used so much hot water in a shower that his fellow servicemen left him out in the cold for a period of time, and volunteering for snow removal despite lack of knowledge of the equipment. He stated that he had his nose broken in a fight, and got caught sleeping on guard duty. He related that he had begun drinking a lot in service. He stated that in 1963, as a result of his behavior, his platoon sergeant referred him to the dispensary for psychiatric treatment, but that once there, he talked his way out of it. There were no other instances of psychiatric treatment or referral. A letter dated from T. Blue dated in January 1993 was to the effect that he had known the veteran most of his life, both before and after service. Following service, the veteran seemed to be a much different person. The veteran had recounted many instances in service of bizarre or inappropriate behavior. Subsequent to service, in about 1966, they both worked for the same employer, but the veteran's problems in dealing with supervision caused him to quit, and he drifted from job to job after that. In addition, the veteran began drinking heavily in service which continued until he quit in 1983. G. Blue wrote, in January 1993, that he had known the veteran his entire life, and that the veteran had been changed since his return from service in 1965. The veteran had described a cross country trip immediately after service during which he had compulsively driven for hours on end, until he began hallucinating. That had been followed by a period of restlessness and inability to keep a job that continued until he was unable to work at all. W. Carrosquel wrote, in January 1993, that he and the veteran "went back a long way," and that the veteran experienced mood swings while in service which continued after he was discharged, and were later diagnosed as manic depressive behavior. He related that the veteran went through a series of jobs starting in 1965 when he was discharged, and that his employment difficulties had continued to the present day. The only job he kept for any period of time, about 10 years, was as a merchant seaman; and that was because the job by its nature consisted of irregular work. Although the veteran genuinely wanted to work, he was unable to because of his deep underlying problems, and although his first hospitalization was in 1976, it was the writer's opinion that the veteran had been having the problems for years. The veteran also submitted copies of W-2 forms dated in 1966 and 1967, as well as state employment security department monetary determination (unemployment compensation) dated in July 1967 and September 1968, with eligibility based on earnings in 1966 and 1967. He also submitted copies of transcripts from two community colleges, showing his attendance from spring 1971 through winter 1975-76, with a grade point average of 3.51, attaining an AAS in Marine Engineering Technology. The second record shows his attendance at another community college in the spring of 1976 and the summer of 1977, during which he received a grade point average of 2.0 and several "incompletes." A VA examination for compensation purposes was performed in December 1993. On psychiatric examination, the claims file was reviewed, and the examiner noted a diagnosis of schizoaffective schizophrenia in December 1977 with possible manic depressive disorder. Later, the diagnosis was changed to bipolar affective disorder, although it was noted that the schizoaffective versus bipolar controversy seemed to continue in the record. The veteran was taking lithium, Mellaril and desipramine. He noted that the treating psychiatrist at the VA also had recently diagnosed post-traumatic stress syndrome. There was also a question of rapid cycling bipolar disorder. The veteran stated he had been on Social Security disability since 1977. Currently, his chief symptoms were periodic depression every five to seven weeks, lasting from two to five days, as well as an occasional possible manic episode of a few hours duration. He reported some behavior in the military that the examiner noted sounded manic in nature, including dressing in women's clothing for fun on one occasion, and wanting to operate at 3:00 a.m. a snow removal machine with which he had no experience. The veteran indicated his irreverent behavior had caused problems with his superiors, and that at one time they wanted him to see a psychiatrist, but he refused. A medical discharge had been mentioned on several occasions. He stated he had had crying spells in service as well. The veteran also reported a history of alcohol abuse, although he had not drunk since April 1989. He indicated his mother had been depressed and had an alcohol problem, and his father had been abusive. The diagnoses were bipolar disorder, possibly rapidly cycling, history of alcohol dependence, in remission, and PTSD to be ruled out. It was noted that the accepted diagnosis now appeared to be bipolar illness. The examiner felt that he could not verify whether the symptoms manifested themselves initially in a more serious way when the veteran was in the military. In response to a request from the VA in November 1994, the veteran submitted the journal he kept regarding his military experiences which included those mentioned at the hearing and on other occasions. He related that he had written the journal in 1984, and that he had not kept a contemporaneous record. Analysis Service connection may be established for chronic disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1994). If the disability is a psychosis, service connection may be established if the disability was manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 , 1131 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1994). In this case, there are unfortunately no service medical records except for a clinical record cover sheet indicating a hospitalization for a flu syndrome. Where service medical records are unavailable, the Board has a heightened obligation to explain its findings and conclusions and to consider the benefit- of-the-doubt rule. O'Hare v. Derwinski, 1 Vet.App. 365 (1991). In this case, however, it should be pointed out that the veteran has stated on a number of occasions that he did not receive any psychiatric treatment or evaluation in service. The evidence in the veteran's favor consists of his own written statements and testimony regarding his claimed inservice experiences which he contends were reflective of a "manic" phase of his illness. Further, letters have been received from three long-time acquaintances of the veteran, stating that the veteran's behavior changed upon his return from service. However, the probative value of this evidence is limited by the fact that the statements were all made many years after the events in question. In addition, a VA psychologist who has treated the veteran for several years has reviewed a journal kept by the veteran pertaining to service, and concluded that this journal reflects clear evidence of the presence of a bipolar disorder in service. It is important to note, however, that the probative value of the this conclusion is limited by the fact that the journal relied upon by the psychologist was purportedly written in 1984, at least 18 years after service, and several years after psychiatric illness was initially diagnosed. Thus, the conclusions reached by the psychologist, who apparently was under the impression that the journal was written while the veteran was in service, were based on the history provided by the veteran, and transcribed many years after the events. The Board is not bound to accept medical opinions based on history provided by the veteran; "[t]heir diagnoses can be no better that the facts alleged by the appellant." Swann v. Brown, 5 Vet.App. 231, 233 (1993). In addition, to the extent that the opinion was based on the language and tone of the journal itself, suggested by the description of the speech as pressured, incoherent and inappropriately idiosyncratic, with grandiose delusions, any idiosyncrasies or peculiarities revealed in the journal itself must be attributed to the psychiatric disorder the veteran undisputedly had at the time the journal was written. The evidence against the veteran consists of the absence of any contemporaneous account of psychiatric abnormality for a decade after service, until 1976, when a two year history of pertinent symptomatology was noted. When first considered for VA hospitalization in August 1976, the veteran reported problems all his life, stating that he had had a couple of nervous breakdowns previously, but that he had functioned fairly well until about 1- 1/2 years earlier. No link to service was reported. During the hospitalization, a history of psychiatric problems beginning in 1975 was noted. In 1976, he filed a claim for VA pension benefits, based on a mental disorder beginning in 1976. In addition, a case summary in 1988 indicated a "13+" year history of the illness, with no mention of service, which would have been nearly 23 years earlier at that point. In addition, although the veteran has stated that he had numerous problems with authority throughout service, including disciplinary actions, and that a medical discharge was recommended, his DD 214 tends to argue against significant behavioral problems at that time, showing a regular, honorable discharge and that he was promoted from E-1 to E-4 during his slightly less than 3 years of service. The veteran has submitted copies of transcripts and W-2 forms in support of his claim, as well as community college transcripts pertaining to the years 1971 through 1977, which are essentially of no probative value. The W-2 and unemployment entitlement forms, dated in 1966, 1967 and 1968, are evidently intended to show erratic employment during this period. However, there are many reasons other than a psychiatric disorder which can account for erratic employment, including the economy, the nature of the employment, e.g., permanent versus temporary, or manufacturing employment subject to layoffs, as well as other co-existing disorders, such as, in this case, an alcohol dependence that was apparently present for the first several years after service. The transcripts, which show the veteran successfully attained an associate's degree in 1976, with a subsequent, less successful attempt at school, tend to indicate he was functioning better from 1971 to early 1976 than later. Again, however, there are so many unrelated variables that could account for his performance that we do not believe this to be of any probative value. Thus, the positive evidence in this case is outweighed by the negative evidence. In this regard, the earliest evidence suggesting a connection to service was received when the veteran filed his claim for service connection in 1991, over 25 years after his separation from service. He submitted a journal detailing his recollections of service experiences in 1994, which he stated he wrote in 1984, still many years after service. Consequently, the positive evidence, based entirely on recollections of events occurring many years previously, is necessarily less probative than contemporaneous evidence, which first shows a psychiatric disorder in about 1975. Of significance is the history provided then and during the succeeding years, through the 1988 case summary, ascribing the onset to the period from about 1973 to 1975. Accordingly, the preponderance of the evidence is against the claim for service connection for an acquired psychiatric disorder. ORDER Service connection for an acquired psychiatric disorder is denied. JACK W. BLASINGAME 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.