Citation Nr: 1215841 Decision Date: 05/02/12 Archive Date: 05/10/12 DOCKET NO. 93-06 994 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for alcoholism including as secondary to an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty for training from May 1980 to September 1980 and on active duty from August 1984 to August 1985. This appeal comes before the Board of Veterans' Appeals (Board) from a June 1992 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board denied service connection for an acquired psychiatric disorder and alcoholism in November 1994, November 1997, and March 2006. The Veteran appealed the decisions to the U.S. Court of Appeals for Veterans Claims (Court). In April 1996, November 1998, and November 2007, the Court vacated the decisions and remanded the appeal for compliance with instructions in a Joint Motion for Remand or a Memorandum Decision. The Board remanded the appeal for further development in November 1996, June 1999, June 2005, July 2008, and January 2010. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. REMAND The Board acknowledges that the Veteran's claims have been under evidentiary development and adjudication for more than twenty years. Nevertheless, service treatment records received in April 2010 are relevant to the claims and were not specifically evaluated in the most recent VA examination. Further, the Veteran submitted statements received in January and February 2012 that identified additional psychiatric treatment and diagnoses. Records of this treatment have not been associated with the claims file and were also not available during the most recent VA examination. The Veteran served as a U.S. Army missile launcher crew member. He contends that symptoms of an acquired psychiatric disorder first manifested in service and proximately caused or aggravated alcohol abuse. In several lay statements, the Veteran, his family members, and an acquaintance reported that abnormal behavioral symptoms first manifested during the Veteran's period of active duty in 1984-85. The Veteran reported that he experienced stress and anxiety from marital discord, a divorce, separation from his children, disappointment in removal from a military occupation because of a vision deficit, and disappointment in not being accepted for officer training. There are no service treatment records in the file from the Veteran's period of active duty for training in 1980, but an Army Reserve physical examination in November 1982 and a June 1984 enlistment examination are silent for any psychiatric abnormalities or reported symptoms. The Veteran noted that he had a pending application for officer training. An examiner noted that the Veteran failed a color recognition test but was able to distinguish red from green. The Veteran started a period of active duty in August 1984. Records of a self-referred psychiatric examination at the Veteran's first duty station in the United States were obtained by the Appeals Management Center in April 2010. In September 1984, the Veteran was in a training status, and his drill sergeant reported that the Veteran was under strain and unable to concentrate on his training and duties because his wife was deployed overseas and wanted a divorce. The sergeant noted that the Veteran's character was excellent but that his efficiency was fair. The Veteran displayed a good attitude, got along well with others, and had no behavior problems. In a social history questionnaire, the Veteran reported that he was a college graduate and married since 1977 but separated from his wife since 1983. He reported that his wife requested a divorce and that he wanted a discharge from service so that he could seek custody of his children. He reported symptoms of anxiety, depression, a lack of self-confidence, and an inability to concentrate because of the marital issues. A military mental health examiner noted that the Veteran reportedly knew about the divorce before starting active duty and was using the situation to avoid the remainder of his enlistment. The examiner and a social work officer recommended stress management therapy. There was no diagnosis of a psychiatric disorder. The examiner noted that a report would be made to the unit commander but that the Veteran was psychiatrically cleared for further duty. After reporting to a duty station overseas, the Veteran was initially assigned to a unit with duties involving nuclear weapons, but was reassigned after he failed another color recognition test and could not distinguish red from green. In April 1985, the Veteran self-referred for alcohol abuse treatment. Clinical staff recommended an inpatient program, but the Veteran chose to attempt an outpatient program of awareness and education classes and five counseling sessions. The Veteran failed to report to duty on two occasions in May and June 1985 because of intoxication. In July 1985, his commanding officer initiated administrative discharge procedures for failure of the alcohol rehabilitation program. In a rebuttal statement, the Veteran acknowledged his alcohol abuse which he attributed to his divorce and loss of opportunity to contest custody of his children because of his overseas duty assignment. The Veteran underwent a discharge physical examination and reported symptoms of depression, excessive worry, loss of memory, and nervous trouble. In the original examination report, a military physician checked a box noting no psychiatric abnormalities and did not comment on the Veteran's reported symptoms. (Copies of this report in the file show this block are blank for unexplained reasons.) In early August, a civilian physician noted that the Veteran was "obviously intoxicated" and sent him for a blood alcohol test. The same day, the same physician noted in a different report that the Veteran's mental status was normal with no anxiety, depression, or memory deficits and that he was mentally capable of understanding the discharge proceedings. The Veteran initially received a general discharge under honorable conditions for alcohol abuse rehabilitation failure. An Army Discharge Review Board upgraded the character of service to honorable but retained the reason for discharge as rehabilitation failure. Private treatment records starting in 1989 showed that the Veteran has been diagnosed with several psychiatric disorders including anxiety disorder, depressive disorder, decompensating schizophrenia, "nervous disorder," and alcohol dependence. Comments by private physicians later in the history placed the start of alcohol abuse treatment in 1988. The Veteran has also been diagnosed with a personality disorder. Although some clinicians noted marital problems as the start of his anxiety, most did not review the claims file or specifically attribute the various disorders to military service. In lay statements, the Veteran, his family, and a friend attributed the disorders to the Veteran's inability to cope with Army life and the onset of behavioral problems to active duty service. In 1992, the Social Security Administration granted disability benefits for a personality disorder and a psychoactive substance addiction disorder. In an August 1996 SSA review examination, the Veteran reported that he experienced nervousness or worry all his life and abused alcohol prior to military service. In August 1997, another SSA examiner noted that he was unable to separate the symptoms of depression, alcohol abuse, and personality disorder. In April 2005, a hospital examiner noted a history of decompensating schizophrenia. In an October 1992 substantive appeal, the Veteran reported that he used alcohol during service to cope with the "military pressure" of life in a barracks and disappointment regarding duty assignments. He noted that his wife wanted a military career. He noted that he did not want a military career and that he initiated the divorce. The file contains three medical opinions on the origins of the disorders. In August 2005, a VA psychiatrist and a chief of mental health service summarized the history in detail and referred to several documents in the claims file including employment and criminal arrest records. The examiners discussed the service treatment and personnel records but did not have the records of the September 1984 examination. The examiners diagnosed alcohol dependence, personality disorder, and provisional anxiety disorder. It was not possible to determine whether the anxiety disorder caused or was the result of alcohol. The examiners also noted that the diagnostic criteria for a generalized anxiety disorder do not include the physiological effects of substance abuse. The examiners concluded that the Veteran's social and occupational impairment preceded active duty and were the result of a personality disorder and alcohol abuse. In November 2010, the Veteran's primary care physician noted briefly on a prescription pad that it was "very probable" that the Veteran drank alcohol because of anxiety. The physician noted that the history was obtained from the Veteran and did not provide an explanation for the opinion. In May 2011, a VA psychiatrist noted a review of the claims file which at that time contained the records of the September 1984 examination and the earlier opinions. However, the psychiatrist noted that her review included the service records but not private records, and she did not refer to any specific service records other than the unsuccessful alcohol abuse treatment in 1985. The psychiatrist noted that the Veteran was now experiencing hallucinations associated with alcohol use. The psychiatrist diagnosed chronic alcohol abuse with hallucinosis, anxiety disorder, cognitive disorder, and personality disorder and concluded that the Veteran's current disorders were not related to service and that alcoholism was not caused or aggravated by a psychiatric disorder. The psychiatrist explained that the first complaints of a discrete psychiatric disorder were in 1989. The psychiatrist concluded that evidence of a dysfunctional personality preceded service and that alcohol abuse was not likely caused by family separation or disappointment regarding officer training. The psychiatrist did not comment on the earlier opinions or address the symptoms in September 1984, symptoms on the July 1985 discharge examination, or the lay statements and did not explain why those symptoms were not manifestations of the later diagnoses. It remains unclear whether the symptoms of anxiety and depression reported in service caused alcohol abuse or were the result of alcohol abuse. Therefore, the Board concludes that an additional medical review and complete rationale are necessary to decide the claims. 38 C.F.R. § 3.159(c) (2011). Further, in statements in January 2012 and February 2012, the Veteran reported that he was receiving treatment for anxiety from a private psychiatrist in Danville, Kentucky who told him that the anxiety noted in service was related to the generalized anxiety disorder diagnosed in 1989. The Veteran also reported that he was receiving treatment for hallucinations at the "Hazard VA clinic" and was diagnosed with posttraumatic stress disorder. The Veteran referred to an "Enhanced Range Program" that was helping with anxiety and depression but did not identify the location or providers of this care. The Veteran identified additional treatment records including VA records that are relevant to the claim. These records must be requested and associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. Request from the Veteran the name and address of his private psychiatrist in Danville, Kentucky and the providers of the "Enhanced Range Program" and authorization to obtain records of mental health care. If authorized, request all available records and associate any records received with the claims file. 2. Request all records of VA mental health treatment including from the "Hazard VA clinic" and associate any records received with the claims file. 3. Then, provide the entire claims file to the VA psychiatrist who performed the May 2011 examination, if available, or to another qualified psychiatrist or doctoral-level psychologist. Request that the examiner review the claims file and note the review in an examination report. Request that the examiner note a review of the Board's summary of evidence above including the referenced service treatment and personnel documents. Request that the examiner provide answers to the following questions: a. Were the Veteran's symptoms noted by the drill sergeant and reported to a medical examiner in service in September 1984, subsequent alcohol abuse and treatment failure, disciplinary incidents, and symptoms reported to the discharge physical examiner in July 1985 manifestations of an acquired psychiatric disorder that continued until diagnosed after service in 1989, and why? b. Were any of the post-service diagnoses of acquired psychiatric disorders reasonably related to any aspect of service including marital discord, divorce, separation from children, general Army barracks life, or disappointment in duty assignments and why? c. If an acquired psychiatric disorder manifested in service, was the Veteran's chronic alcohol abuse proximately caused or aggravated by that acquired psychiatric disorder or did an acquired disorder or personality disorder cause or aggravate the alcohol abuse and why? d. A complete explanation of the bases for the answers and opinions with reference to relevant documents in the file are necessary and will be of considerable assistance to the Board. If an opinion cannot be offered without resort to speculation, the examiner must provide the reasons such as absence of relevant evidence, shortfalls in the extent of current medical knowledge, or lack of training or experience of the examiner. 4. Review the claims file to ensure that all the foregoing requested development is completed, and arrange for any additional development indicated. Then, readjudicate the claim for service connection for an acquired psychiatric disorder and for service connection for alcoholism as secondary to an acquired psychiatric disorder. If any benefit sought remains denied, issue an appropriate supplemental statement of the case and provide the appellant and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The purpose of this remand is to assist the appellant with the development of his claim. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim is both critical and appreciated. [Continued on following page.] This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2011). _________________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2011).