Citation Nr: 0813871	
Decision Date: 04/25/08    Archive Date: 05/01/08

DOCKET NO.  01-09 288	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Roanoke, 
Virginia


THE ISSUES

1.  Entitlement to service connection for a stomach disorder 
(to include irritable bowel syndrome), including as secondary 
to service-connected Bell's palsy.

2.  Entitlement to service connection for a mental disorder 
(to include depression and bipolar disorder), including as 
secondary to service-connected Bell's palsy.


REPRESENTATION

Veteran represented by:	Kathy A. Lieberman, Esq.


ATTORNEY FOR THE BOARD

L. B. Yantz, Associate Counsel

INTRODUCTION

The veteran served on active duty from April 1987 to April 
1990.

This matter has come before the Board of Veterans' Appeals 
(Board) on appeal from two rating decisions (dated March 2000 
and August 2001) of the Roanoke, Virginia Department of 
Veterans Affairs (VA) Regional Office (RO), which denied 
service connection for a stomach disorder and for depression, 
to include both as secondary to the veteran's service-
connected Bell's palsy.  The March 2000 rating decision 
denied both claims for not being well-grounded.  The August 
2001 rating decision denied both claims on the merits.

In June 2003 and July 2005, the Board remanded this appeal to 
the RO (via the Appeals Management Center (AMC) in 
Washington, DC) for further development.

In June 2006, the United States Court of Appeals for Veterans 
Claims (Court) granted a joint motion to remand this appeal 
to the Board.

In March 2007, pursuant to the Court's joint motion to 
remand, the Board once again remanded this appeal to the RO 
via the AMC for further development.

During VA examinations in November 2007, the veteran was 
diagnosed with irritable bowel syndrome (IBS) and bipolar 
disorder not otherwise specified, but was not given a 
diagnosis of depression.  The United States Court of Appeals 
for the Federal Circuit has held that a newly diagnosed 
disorder, whether or not medically related to a previously 
diagnosed disorder, cannot be considered the same claim when 
the newly diagnosed disorder has not been considered by 
adjudicators in a previous decision.  Ephraim v. Brown, 82 
F.3d 399, 401-402 (Fed. Cir. 1996).  Therefore, the Board has 
rephrased the issues listed on the title page to better 
reflect the claims currently on appeal.

The veteran had previously been represented in this matter by 
Virginia Department of Veterans Services.  However, in 
January 2008, the veteran appointed Kathy A. Lieberman, Esq. 
to be her representative.

For reasons explained below, the issue of entitlement to 
service connection for a mental disorder (to include 
depression and bipolar disorder), including as secondary to 
service-connected Bell's palsy, is addressed in the REMAND 
portion of the decision below and is REMANDED to the RO via 
the AMC.


FINDING OF FACT

The evidence of record does not show a stomach disorder (to 
include IBS) to have been caused or made worse by active 
military service or by the service-connected Bell's palsy.


CONCLUSION OF LAW

A stomach disorder (to include IBS) was not incurred in or 
aggravated by active military service, nor is it proximately 
due to or the result of the veteran's service-connected 
Bell's palsy.  38 U.S.C.A. §§ 1131, 5107(b) (West 2002); 38 
C.F.R. §§ 3.102, 3.303, 3.310 (2007); Allen v. Brown, 7 Vet. 
App.439 (1995) (en banc).


REASONS AND BASES FOR FINDING AND CONCLUSION

The Veterans Claims Assistance Act (VCAA)

The VCAA, codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5106, 
5107, and 5126, was signed into law on November 9, 2000.  
Implementing regulations were created, codified at 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159, and 3.326 (2007).

VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 
C.F.R. § 3.159(b) must: (1) inform the claimant about the 
information and evidence not of record that is necessary to 
substantiate the claim; (2) inform the claimant about the 
information and evidence that VA will seek to provide; (3) 
inform the claimant about the information and evidence that 
the claimant is expected to provide; and (4) request or tell 
the claimant to provide any evidence in the claimant's 
possession that pertains to the claim.  Pelegrini v. 
Principi, 18 Vet. App. 112, 120-121 (2004) (Pelegrini II).  
This "fourth element" of the notice requirement comes from 
the language of 38 C.F.R. § 3.159(b)(1).  Charles v. 
Principi, 16 Vet. App. 370, 373-74 (2002); Quartuccio v. 
Principi, 16 Vet. App. 183, 186-87 (2002).

The Court held in Pelegrini II that VCAA notice, as required 
by 38 U.S.C.A. § 5103(a) (West 2002), to the extent possible, 
must be provided to a claimant before the initial unfavorable 
RO decision on a claim for VA benefits.  Pelegrini II, 18 
Vet. App. 112, 119-20 (2004).  See Mayfield v. Nicholson, 444 
F.3d 1328 (Fed. Cir. 2006).

A review of the record reveals that the veteran received VCAA 
notice in March 2001, July 2003, and March 2007.  Thus, she 
was not provided notice of the VCAA prior to the initial 
adjudication of her claims in the March 2000 rating decision 
at issue.  The Board notes, however, that this would have 
been both a practical and a legal impossibility, because the 
VCAA was not enacted until November 2000.  The veteran's 
claims were readjudicated and a new rating decision was 
issued in August 2001 following VCAA notice compliance 
action.  The veteran was provided with every opportunity to 
submit evidence and argument in support of her claims, and to 
respond to the VA notices.  Therefore, there is no prejudice 
to the veteran in proceeding to consider her claim for 
service connection for a stomach disorder (to include IBS) 
(including as secondary to service-connected Bell's palsy) on 
the merits.  Cf. Bernard v. Brown, 4 Vet. App. 384 (1993).

The VCAA letters summarized the evidence needed to 
substantiate the claims and VA's duty to assist.  They also 
specified the evidence that the veteran was expected to 
provide, including the information needed to obtain both her 
private and VA medical treatment records.  In this way, the 
VCAA letters clearly satisfied the first three "elements" of 
the notice requirement.  In addition, the March 2001 letter 
stated: "You can help us with your claim by telling us about 
any additional information or evidence that you want us to 
try to get for you," and the July 2003 and March 2007 letters 
stated: "It is your responsibility to make sure we receive 
all requested records that are not in the possession of a 
Federal department or agency."  (Emphasis in originals).  
This statement satisfied the fourth "element" of the notice 
requirement, in that it informed the veteran that she could 
submit any and all evidence which was pertinent to her 
claims, and not merely that evidence requested by the RO.

During the pendency of this appeal, on March 3, 2006, the 
Court issued a decision in the consolidated appeal of 
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which 
held that the VCAA notice requirements of 38 U.S.C.A. § 
5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements 
of a service connection claim.  Those five elements include: 
1) veteran status; 2) existence of a disability; (3) a 
connection between the veteran's service and the disability; 
4) degree of disability; and 5) effective date of the 
disability.  The Court held that, upon receipt of an 
application for a service connection claim, 38 U.S.C.A. § 
5103(a) and 38 C.F.R. § 3.159(b) require VA to review the 
information and the evidence presented with the claim and to 
provide the claimant with notice of what information and 
evidence not previously provided, if any, will assist in 
substantiating or is necessary to substantiate the elements 
of the claim as reasonably contemplated by the application.  
Id. at 486.  Additionally, this notice must state that a 
disability rating and an effective date for the award of 
benefits will be assigned if service connection is granted.  
Id.

In the present appeal, the veteran received Dingess notice in 
March 2007 and February 2008, including as it relates to the 
downstream disability rating and effective date elements of 
her claims.

The Board finds that all relevant evidence necessary for an 
equitable resolution of the issue of entitlement to service 
connection for a stomach disorder (to include IBS) (including 
as secondary to service-connected Bell's palsy) on appeal has 
been identified and obtained, to the extent possible.  The 
evidence of record includes service medical records, QTC 
examination reports, private medical records, employment 
records, a Veterans Health Administration (VHA) medical 
opinion, VA examination reports, and statements from the 
veteran and her representative.  The veteran has not 
indicated that she has any further evidence to submit to VA, 
or which VA needs to obtain.  There is no indication that 
there exists any additional evidence that has a bearing on 
this case that has not been obtained.  The veteran and her 
representative have been accorded ample opportunity to 
present evidence and argument in support of her appeal.  All 
pertinent due process requirements have been met.  See 38 
C.F.R. § 3.103 (2007).

In short, the Board has carefully considered the provisions 
of the VCAA in light of the record on appeal, and for the 
reasons expressed above, it finds that the development of the 
claim for service connection for a stomach disorder (to 
include IBS) (including as secondary to service-connected 
Bell's palsy) has been consistent with these provisions.  
Accordingly, the Board will proceed to a decision on the 
merits.

Pertinent Laws and Regulations

Service connection may be granted for disability resulting 
from disease or injury incurred in or aggravated by active 
service.  38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 
3.303(a) (2007).  In addition, service connection may be 
granted for any disease diagnosed after discharge, when all 
of the evidence, including that pertinent to service, 
establishes that the disease was incurred in service.  38 
C.F.R. § 3.303(d).

In order to establish service connection for a claimed 
disorder on a direct basis, there must be: (1) medical 
evidence of a current disability; (2) medical, or in certain 
circumstances, lay evidence of the in-service incurrence or 
aggravation of a disease or injury; and (3) medical evidence 
of a nexus between the claimed in-service disease or injury 
and the current disability.  See Hickson v. West, 12 Vet. 
App. 247, 253 (1999).

Service connection may also be established on a secondary 
basis for a disability which is proximately due to or the 
result of a service connected disease or injury; or, for any 
increase in severity of a nonservice-connected disease or 
injury that is proximately due to or the result of a service-
connected disease or injury, and not due to the natural 
progression of the nonservice-connected disease.  38 C.F.R. 
§ 3.310(a)-(b) (2007); Allen v. Brown, supra.

In order to establish service connection for a claimed 
disability on a secondary basis, there must be: (1) medical 
evidence of a current disability; (2) a service-connected 
disability; and (3) medical nexus evidence establishing a 
connection between the service-connected disability and the 
current disability.  See Wallin v. West, 11 Vet. App. 509, 
512 (1998).

Factual background

In-service evidence

The service medical records reflect that, beginning in 
approximately December 1987, the veteran began presenting 
with complaints of stomach pains and abdominal cramps.  She 
was pregnant during this time frame.  In February 1988, when 
the veteran was four months pregnant, she presented with a 
complaint of a sharp, throbbing stomach pain, and she 
reported that she had an abdomen "accident" (quotes in 
original) as a result of having been hit in her stomach 
accidentally while wrestling.  In July 1988, she delivered a 
female child.  Eight days post-partum, the veteran 
experienced pronounced portio displacement pain and elevated 
body temperature, both indicative of endometriosis.

In mid-April 1989, the veteran presented with a complaint of 
personal problems and related that she wanted to know when a 
urine test would show pregnancy, as her menstrual period was 
seven days late and she felt nauseated.  Two days later, the 
veteran presented with complaints of diarrhea, nausea, aching 
all over, and chills for three days.  She related that the 
nausea and chills were her worst complaints.  Examination of 
her abdomen revealed increased bowel sounds without menses.  
The examiner assessed gastroenteritis.

In late April 1989, the veteran presented with complaints of 
abdominal cramps and throwing up blood during the prior two 
weeks, and that the spitting up of blood had increased during 
the prior five days.  She described her pain as in the middle 
of her abdomen and denied diarrhea or constipation.  Further 
inquiry, however, revealed that she had not had a bowel 
movement for the last 14 days.  Physical examination of the 
abdomen revealed soft, mild generalized tenderness all over 
her abdomen.  There was no counter tenderness, no mass, and 
bowel sounds were normal.  The examiner, Dr. S., assessed 
hematemesis of questionable etiology, and he called internal 
medicine which directed her referral to the emergency room 
for further work-up.  Subsequent referral and examination 
revealed her to have a Mallory-Weiss tear and an intrauterine 
pregnancy.

The veteran's service medical records reflect no entries for 
further abdominal symptomatology after the intrauterine 
pregnancy, which was terminated in March 1990.  In fact, 
except for the elective sterilization, her service medical 
records fall silent after June 1989, when she complained of 
upper abdominal pain and cramping, and nausea and vomiting 
four times that morning.  There was mild generalized 
tenderness in her left side, no rigidity, no point or resound 
tenderness, and no tenderness over her pelvis.  Bowel sounds 
were increased.  Dr. S. assessed a viral syndrome.

Post-service evidence

Private treatment records of Dr. J.W.B. reflect that, in 
February 1996, the veteran presented for her initial visit 
with a complaint of having experienced lower abdominal pain 
after eating, which she said had started in August 1995, then 
seven months earlier.  She also reported nausea.  Dr. J.W.B. 
assessed suspected IBS and referred her for clinical tests.  
A March 1996 note reflects that the clinical tests revealed 
no significant pathology, and Dr. J.W.B. noted continued 
management of IBS as the course of treatment.  In October 
1999, the veteran presented with complaints of recurrent left 
lower quadrant pain, and Dr. J.W.B. noted underlying IBS, 
with no comment on etiology.  In November 1999, Dr. J.W.B. 
noted that her symptoms were quite intermittent.

In January 2000, private Dr. M.C. referred the veteran to a 
GI doctor for her recurrent complaints of continued abdominal 
symptomatology.  A February 2000 note of private Dr. I.P. 
reflects that the veteran reported her IBS diagnosis of 1996, 
and that she had symptoms 15 days out of 30.  Dr. I.P. noted 
her history of depression and advised her that it was 
important that she adhere to a high fiber diet and drink 
plenty of water.

An August 2000 report of private Dr. M.J.R., a digestive and 
liver disease specialist, reflects that he saw the veteran 
for a four to five-year history of intermittent lower 
abdominal discomfort.  He noted that all of her clinical 
tests, i.e., extensive radiologic and endoscopic evaluations, 
were unrevealing.  The veteran related that, in 1996, she 
started having intermittent lower abdominal discomfort which 
had increased in frequency and severity, and was then up to 
two to three times a week.  Dr. M.J.R. noted that the veteran 
apparently was in military service for six years, and that 
she did not have any abdominal discomfort at that time.  
Following physical examination, he assessed probable IBS.  
The veteran apparently provided copies of her service medical 
records to Dr. M.J.R. and requested an opinion from him.  His 
February 2001 report states: "[I have] reviewed the records 
you have sent me.  It is certainly possible that you had IBS 
while in the Service.  I can only state that it is possible 
(as opposed to probable) that your IBS was a result of your 
time in the Service."  (Emphasis in original).

In an undated report received by the RO in July 2002, R.T., a 
licensed marriage and family therapist, related that he had 
seen the veteran on two occasions.  Mr. R.T. opined that, 
after his sessions with the veteran as well as a thorough 
review of her records, it was highly probable that her 
current "condition" was caused by or directly related to her 
military service and traumatic situations she experienced.

An October 2003 QTC examination report shows that the veteran 
had been experiencing a spastic colon since 1988.  She 
reported nausea and vomiting as often as twice a week, which 
usually was brought on by anxiety.  She also reported 
frequent left quadrant stomach pain which was sharp or 
stabbing.  Following physical examination, the QTC examiner 
rendered a diagnosis of intermittent symptomatic 
gastroparesis.  Subjective factors noted were history, and 
the objective factors noted were current pharmacotherapy.  
The RO asked the examiner to opine as to any relationship 
between the veteran's Bell's palsy and her abdominal 
symptomatology.  The examiner observed that there is no 
documented association of Bell's palsy and gastrointestinal 
pathology, as Bell's palsy involves abnormal function of 
cranial nerve VII, whose innervation does not influence the 
gastrointestinal tract.  The RO also asked the examiner to 
provide a nexus opinion as to any relationship between the 
veteran's abdominal symptomatology and whether it had its 
onset in service between April 1987 and April 1990.  The RO 
specifically requested that he consider and comment on the 
July 2002 opinion of R.T., the licensed marriage and family 
therapist.  The examiner noted that, in his opinion, the 
veteran had a gastrointestinal disorder diagnosed as stress 
related gastritis.  He answered simply, "Yes," as to whether 
it had its onset between 1987 and 1990.  He also repeated 
that there was no relationship with the veteran's Bell's 
palsy.

A March 2004 deferred rating decision reflects that the RO 
deemed this October 2003 QTC examination to be insufficient 
for rating purposes and asked the examiner for clarification.  
In his April 2004 response, the examiner stated that the 
veteran was diagnosed with stress related gastritis, 
otherwise termed IBS, with symptoms as early as April 27, 
1989, as evaluated by Dr. S. in service.  The examiner denied 
seeing any record of Mr. R.T.'s opinion.

In May 2005, the Board requested VHA to provide or obtain an 
expert medical opinion, because the April 2004 opinion was 
deemed to be insufficient for rating purposes.  VHA referred 
the claims file to Dr. R.C., Director of the Inflammatory 
Bowel Disease Program at a local university.  The Board 
requested that, in addition to the overall history of 
abdominal symptoms reported by the veteran from 1987, the 
reviewer consider the veteran's OB-GYN symptomatology and the 
April 1989 diagnosis of a Mallory-Weis tear, and to opine 
whether her in-service symptoms were those of IBS.

In his May 2005 opinion for VHA, Dr. R.C. observed that the 
cause of the veteran's symptoms which began in December 1987 
was uncertain.  As to her symptoms later in her period of 
service, he observed that it was possible that the veteran's 
symptoms were from IBS but, unfortunately, it was impossible 
to determine that with certainty, especially in the setting 
of concomitant pregnancy.  He noted that it was equally 
possible that her symptoms were related to pregnancy alone, 
and that her symptoms of recurrent nausea during her second 
pregnancy were more consistent with nausea and vomiting of 
pregnancy, though it also was possible that the symptoms were 
a variant of IBS.  Concerning the veteran's post-service 
symptomatology, Dr. R.C. noted that these symptoms are 
consistent with IBS, and that it was probable that her post-
service symptoms are from IBS.  He also noted that it was 
possible that they were related to those manifested during 
her active service, but it was equally likely that her in-
service symptoms were related to pregnancy or some other 
etiology.  Although he was not asked for an opinion as to any 
relationship between the veteran's Bell's palsy and her IBS, 
Dr. R.C. noted that the applicable literature does not report 
any association between facial nerve paralysis and IBS, and 
he observed that a proportion of patients with IBS develop 
symptoms after an infectious gastroenteritis.  The infection 
could be either viral or bacterial in nature, and that, 
interestingly, many viruses are associated with the 
development of both Bell's palsy and IBS.  Therefore, he 
opined, it was possible that a viral infection led to the 
development of both Bell's palsy and IBS.

Pursuant to the March 2007 Board remand, the veteran 
underwent a VA examination in November 2007 to evaluate the 
nature and etiology of her gastrointestinal disorder.  The VA 
examiner reviewed the claims file and medical records for the 
veteran at the time of this examination.  The veteran 
reported that her GI symptoms started in 1988 or 1989, but 
that she was not diagnosed until 2001.  The examiner 
diagnosed her with IBS.  With regard to the question of 
whether the veteran's IBS had its onset during her period of 
service from April 1987 to April 1990, the examiner stated 
the following: "Patient's service medical records [were] 
reviewed, she had lower abdominal pain, nausea with her 
pregnancy.  No other mention of any GI symptoms.  GI symptoms 
are commonly seen with pregnancy.  So irritable bowel onset 
was not during her service years."  With regard to the 
question of whether the veteran's IBS was linked to her 
service-connected Bell's palsy, the examiner stated the 
following: "Her gastrointestinal disorder is not caused by 
Bell's palsy."

Analysis

Direct service connection

As stated above, in order to establish service connection for 
a claimed disorder on a direct basis, there must be: (1) 
medical evidence of a current disability; (2) medical, or in 
certain circumstances, lay evidence of the in-service 
incurrence or aggravation of a disease or injury; and (3) 
medical evidence of a nexus between the claimed in-service 
disease or injury and the current disability.  See Hickson v. 
West, 12 Vet. App. 247, 253 (1999).

The determination as to whether the requirements for service 
connection are met is based on an analysis of all of the 
evidence of record and the evaluation of its credibility and 
probative value.  38 U.S.C.A. § 7104(a); Baldwin v. West, 13 
Vet. App. 1 (1999); 38 C.F.R. § 3.303(a).

With respect to Hickson element (1), there is competent 
medical evidence that a stomach disorder currently exists.  
At the time of her November 2007 VA examination, the veteran 
was diagnosed with IBS.  Hickson element (1) has therefore 
been satisfied for the veteran's claim.

With respect to Hickson element (2), the in-service factual 
background outlined above does show that the veteran 
complained of abdominal pain, nausea, diarrhea, constipation, 
and vomiting while in service.  However, no diagnosis of IBS 
was ever rendered in service.  Instead, various combinations 
of these in-service symptoms were documented along with 
diagnoses of pregnancy (December 1987 to February 1988), 
endometriosis (July 1988), gastroenteritis (April 1989), a 
Mallory-Weiss tear (April 1989), an intrauterine pregnancy 
(April 1989), and a viral syndrome (June 1989).  Hickson 
element (2) has therefore been satisfied for the veteran's 
claim.

With respect to Hickson element (3), medical nexus, the Board 
must weigh the evidence of record and determine which medical 
opinion merits the greater weight.  In that process, the 
Board may favor the opinion of one competent medical expert 
over that of another, provided the reasons therefore are 
stated.  Winsett v. West, 11 Vet. App. 420, 424-25 (1998).

In February 2001, private Dr. M.J.R. stated: "It is certainly 
possible that [the veteran] had IBS while in Service.  I can 
only state that it is possible (as opposed to probable) that 
[her] IBS was a result of [her] time in the Service."  
(Emphasis in original).

In a July 2002 report, therapist Mr. R.T. opined that it was 
highly probable that the veteran's current "condition" was 
caused by or directly related to her military service and 
traumatic situations she experienced.  However, Mr. R.T. did 
not specify the nature of the "condition," the records that 
he reviewed, or the traumatic situations to which he 
referred.

In October 2003, the QTC examiner answered "yes" to the 
question of whether the veteran's gastrointestinal disorder 
(diagnosed as stress related gastritis) had its onset in 
service between April 1987 and April 1990.  In April 2004, 
the QTC examiner attempted to clarify his earlier opinion by 
stating that the veteran's stress related gastritis 
(otherwise termed IBS) began to manifest symptoms as early as 
April 27, 1989, as evaluated by a Dr. S.

In his May 2005 opinion for VHA, Dr. R.C. observed that the 
cause of the veteran's symptoms which began in December 1987 
was uncertain.  As to her symptoms later in her period of 
service, he observed that it was possible that the veteran's 
symptoms were from IBS but, unfortunately, it was impossible 
to determine that with certainty, especially in the setting 
of concomitant pregnancy.  He noted that it was equally 
possible that her symptoms were related to pregnancy alone, 
and that her symptoms of recurrent nausea during her second 
pregnancy were more consistent with nausea and vomiting of 
pregnancy, though it also was possible that the symptoms were 
a variant of IBS.  Concerning the veteran's post-service 
symptomatology, Dr. R.C. noted that these symptoms are 
consistent with IBS, and that it was probable that her post-
service symptoms are from IBS.  He also noted that it was 
possible that they were related to those manifested during 
her active service, but it was equally likely that her in-
service symptoms were related to pregnancy or some other 
etiology.

In November 2007, the VA examiner stated the following: 
"Patient's service medical records [were] reviewed, she had 
lower abdominal pain, nausea with her pregnancy.  No other 
mention of any GI symptoms.  GI symptoms are commonly seen 
with pregnancy.  So irritable bowel onset was not during her 
service years."

In the Board's view, the medical opinions from February 2001 
and May 2005 are too speculative to be probative.  See 
Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. 
Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed 
in terms of "may" also implies "may or may not" and is too 
speculative to establish medical nexus); see also Warren v. 
Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in 
terms such as "could have been" is not probative); Tirpak v. 
Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" 
language by physician is too speculative.

In the Board's view, the opinion from July 2002 is not 
probative because the nature of the veteran's "condition" was 
not specified by Mr. R.T.  Even assuming that the referenced 
condition is gastrointestinal in nature, the Board notes that 
Mr. R.T. is a licensed marriage and family therapist, rather 
than a medical doctor specializing in gastrointestinal 
disorders.  This view is consistent with the Court's decision 
in LeShore v. Brown, 8 Vet.App. 406 (1995), in which it was 
held that a medical professional is not competent to opine as 
to matters outside the scope of his or her expertise, or 
based upon undocumented historical reports.  Thus, an opinion 
may be reduced in probative value, even where the statement 
comes from someone with medical training, if the medical 
issue requires special knowledge.  While the Board does not 
doubt the qualifications of Mr. R.T. as a therapist, there is 
no adequate foundation in the current record to establish 
that he has the requisite background in gastroenterology to 
provide a competent opinion as to whether the veteran's 
current symptoms of IBS are related to her active military 
service.  With all due respect, therefore, his opinion is 
entitled to little probative weight in this case.

In the Board's view, the medical opinions from October 2003 
and April 2004 are not probative because they have both 
already been deemed insufficient for rating purposes.

Therefore, the Board has determined that there is no 
probative medical opinion of record linking the veteran's 
current stomach disorder (IBS) to her military service.  In 
fact, the only probative opinion of record on the subject, 
that from the November 2007 VA examination, is definitively 
against her claim.  As a result of this analysis, Hickson 
element (3) requiring a medical link to service has not been 
satisfied for the veteran's claim.

For the reasons and bases expressed above, the Board finds 
that the preponderance of the evidence is against the 
veteran's claim for direct service connection for a stomach 
disorder (to include IBS).  The benefit sought on appeal is 
accordingly denied to that extent, as there is no reasonable 
doubt concerning this claim to resolve in her favor.  38 
C.F.R. § 3.102; Alemany v. Brown, 9 Vet. App. 518, 519 
(1996).

Secondary service connection

As stated above, in order to establish service connection for 
a claimed disability on a secondary basis, there must be: (1) 
medical evidence of a current disability; (2) a service-
connected disability; and (3) medical nexus evidence 
establishing a connection between the service-connected 
disability and the current disability.  See Wallin v. West, 
11 Vet. App. 509, 512 (1998).

With respect to Wallin element (1), there is competent 
medical evidence that a stomach disorder currently exists.  
At the time of her November 2007 VA examination, the veteran 
was diagnosed with IBS.  Wallin element (1) has therefore 
been satisfied for the veteran's claim.

With respect to Wallin element (2), a service-connected 
disability, the veteran is currently service-connected for 
Bell's palsy (at a 10 percent disability rating).  Wallin 
element (2) has therefore been satisfied for the veteran's 
claim.

With respect to Wallin element (3), medical nexus, the Board 
must weigh the evidence of record and determine which medical 
opinion merits the greater weight.  In that process, the 
Board may favor the opinion of one competent medical expert 
over that of another, provided the reasons therefore are 
stated.  Winsett v. West, 11 Vet. App. 420, 424-25 (1998).

In a July 2002 report, therapist Mr. R.T. opined that it was 
highly probable that the veteran's current "condition" was 
caused by or directly related to her military service and 
traumatic situations she experienced.  However, Mr. R.T. did 
not specify the nature of the "condition," the records that 
he reviewed, or the traumatic situations to which he 
referred.

In October 2003, the QTC examiner observed that there is no 
documented association of Bell's palsy and gastrointestinal 
pathology, as Bell's palsy involves abnormal function of 
cranial nerve VII, whose innervation does not influence the 
gastrointestinal tract.  He later reiterated that there was 
no relationship between the veteran's gastrointestinal 
disorder and her Bell's palsy.

In his May 2005 opinion for VHA, Dr. R.C. noted that the 
applicable literature does not report any association between 
facial nerve paralysis (such as Bell's palsy) and IBS, and he 
observed that a proportion of patients with IBS develop 
symptoms after an infectious gastroenteritis.  The infection 
could be either viral or bacterial in nature, and that, 
interestingly, many viruses are associated with the 
development of both Bell's palsy and IBS.  Therefore, he 
opined, it was possible that a viral infection led to the 
development of both Bell's palsy and IBS.

In November 2007, the VA examiner stated the following: "Her 
gastrointestinal disorder is not caused by Bell's palsy."

In the Board's view, the opinion from July 2002 is not 
probative because the nature of the veteran's "condition" or 
the traumatic situations referred to were not specified by 
Mr. R.T.  Even assuming that the referenced condition is 
gastrointestinal in nature, and even assuming that the 
referenced traumatic situation relates to Bell's palsy, the 
Board notes that Mr. R.T. is a licensed marriage and family 
therapist, rather than a medical doctor specializing in 
gastrointestinal or neurological disorders.  This view is 
consistent with the Court's decision in LeShore v. Brown, 8 
Vet.App. 406 (1995), in which it was held that a medical 
professional is not competent to opine as to matters outside 
the scope of his or her expertise, or based upon undocumented 
historical reports.  Thus, an opinion may be reduced in 
probative value, even where the statement comes from someone 
with medical training, if the medical issue requires special 
knowledge.  While the Board does not doubt the qualifications 
of Mr. R.T. as a therapist, there is no adequate foundation 
in the current record to establish that he has the requisite 
background in gastroenterology or neurology to provide a 
competent opinion as to whether the veteran's current 
symptoms of IBS are related to her Bell's palsy.  With all 
due respect, therefore, his opinion is entitled to little 
probative weight in this case.

In the Board's view, the medical opinion from October 2003 is 
not probative because it has already been deemed insufficient 
for rating purposes.  Even if this opinion were probative, 
the Board notes that it is definitively against the veteran's 
claim.

In the Board's view, the medical opinion from May 2005 is not 
probative because it does not address the question of whether 
the veteran's current IBS was caused or aggravated by her 
service-connected Bell's palsy.  Instead, Dr. R.C. offered a 
opinion stating that a viral infection may have led to the 
development of both Bell's palsy and IBS.

Therefore, the Board has determined that there is no 
probative medical opinion of record linking the veteran's 
current stomach disorder (IBS) to her service-connected 
Bell's palsy.  In fact, the only probative opinion of record 
on the subject, that from the November 2007 VA examination, 
is definitively against her claim.  As a result of this 
analysis, Wallin element (3) requiring a medical link to her 
service-connected disability has not been satisfied for the 
veteran's claim.

For the reasons and bases expressed above, the Board finds 
that the preponderance of the evidence is against the 
veteran's claim for service connection for a stomach disorder 
(to include IBS) as secondary to her service-connected Bell's 
palsy.  The benefit sought on appeal is accordingly denied to 
that extent, as there is no reasonable doubt concerning this 
claim to resolve in her favor.  38 C.F.R. § 3.102; Alemany v. 
Brown, 9 Vet. App. 518, 519 (1996).


ORDER

Entitlement to service connection for a stomach disorder (to 
include IBS), including as secondary to service-connected 
Bell's palsy, is denied.


REMAND

In its March 2007 remand, the Board instructed the RO (via 
the AMC) to schedule the veteran for a VA psychiatric 
examination in order to determine the nature and etiology of 
any current psychiatric disorder.  The Board emphasized that 
the examiner must review all of the evidence in the claims 
folder and acknowledge such review in the examination report.  
In addition to performing all appropriate tests and reporting 
all clinical findings in detail, the examiner was asked to 
answer the following questions: (1) Has the veteran developed 
a psychiatric disorder, and; if so, what is the diagnosis or 
diagnoses?  (2) If the veteran has a current diagnosis of a 
psychiatric disorder: (a) Did such a psychiatric disorder 
have its onset during her period of service from April 1987 
to April 1990? (b) Was such a psychiatric disorder manifested 
within one year after the veteran's discharge from active 
military in April 1990? (c) Was such a psychiatric disorder 
either caused or aggravated by her service-connected Bell's 
Palsy?

Pursuant to these remand instructions, the veteran was 
afforded a VA psychiatric examination in November 2007.  The 
VA examiner stated that he reviewed the claims file and 
medical records for the veteran.  See November 2007 VA 
Psychiatric Examination Report at page 1.  However, the 
examiner went on to state that he did review the service 
medical records, but he did not review VA records or other 
records.  See id. at page 9.  He also confirmed that there 
were no recent medical records available for him to review in 
the claims file.  See id. at page 9.

In the examination report, the examiner noted that the 
veteran was currently seeking weekly treatment from her 
primary doctor (private Dr. L.).  See id. at page 4.  The 
examiner also noted the veteran's primary psychiatrist to be 
private Dr. S.  See id. at page 9.  The claims file does not 
contain treatment records from Dr. L. or Dr. S.  In March 
2008, Dr. S. submitted a statement to the Board, but this 
statement was not accompanied by a waiver of RO jurisdiction, 
and therefore the Board does not have the authority to review 
it at this time.

The examiner also noted that the veteran is on Social 
Security, with a diagnosis of depression.  See id. at page 3.  
Neither the SSA decision awarding such benefits nor the 
medical records used in reaching that determination are of 
record.  The SSA decision and associated records could be 
pertinent to the veteran's claims and should therefore be 
obtained.  See Murincsak v. Derwinski, 2 Vet. App. 363 
(1992).

After evaluating the veteran, the examiner rendered Axis I 
diagnoses of bipolar disorder not otherwise specified, panic 
disorder with agoraphobia, and an eating disorder (as per 
veteran's statements).  See id. at page 7.  The Board notes 
that the examiner did not render a diagnosis of depression.

With regard to the specific questions that the examiner was 
instructed to answer (per the March 2007 Board remand), the 
examiner stated: "Bipolar Disorder / Panic Disorder is less 
likely as not (less than 50/50 probability) caused by or the 
result of Bell's Palsy / Military Experience."  See id. at 
page 9.  The examiner went on to state: "[P]re-military 
symptoms [of bipolar disorder] suggest that such disorder is 
more likely than not to have ante-dated her service."  See 
id. at pages 9-10.  The examiner ended his report by 
commenting that "the claims of Bell's palsy causing [the 
veteran's] mood disorder were blurred during her interview 
due to her own interest in talking more about her claimed 
[military sexual trauma] than about the existence of 
repercussions of her VIIth Nerve Paralysis on her mental 
state."  See id. at page 10.

In view of the November 2007 VA examiner's opinion that the 
veteran's mental disorder most likely began prior to her 
military service, a new VA examination and nexus opinion are 
warranted in order to fully and fairly evaluate the claim on 
appeal to determine if the veteran's mental disorder was 
aggravated by her military service.  In addition, the 
question of whether the veteran's mental disorder was 
aggravated by her service-connected Bell's palsy must also be 
addressed, as the November 2007 VA examiner failed to answer 
the aggravation component of question (2)(c) noted above.

Accordingly, the case is REMANDED for the following actions:

1.  The RO should ask the veteran to 
provide the names, addresses, and 
approximate dates of treatment of all 
health care providers, VA and private 
(including Dr. L. and Dr. S.) who have 
treated her for a mental disorder at 
any time since her discharge from 
active service in April 1990.  After 
securing any necessary authorizations, 
the RO should request copies of all 
indicated records which have not been 
previously secured and associate them 
with the claims folder.  The RO should 
associate the requests and all records 
received with the claims file.  If any 
records are unavailable, then a 
negative reply is requested.

2.  The RO should contact the SSA and 
request that it provide any records 
pertaining to the veteran's award of 
Social Security benefits, including the 
SSA decision and the medical records 
relied upon concerning that claim.  The 
RO should associate the request and all 
records received with the claims file.  
If these records are unavailable from 
the SSA, then a negative reply is 
requested.

3.  After associating with the claims 
folder all available records received 
pursuant to the above-requested 
development, the veteran should be 
afforded a VA psychiatric examination to 
determine the nature, extent, and 
etiology of any mental disability.  It is 
imperative that the examiner who is 
designated to examine the veteran reviews 
ALL of the evidence in the claims folder, 
including a complete copy of this REMAND, 
and acknowledges such review in the 
examination report.  All necessary tests 
should be conducted and all clinical 
findings should be reported in detail.  
The psychiatrist is requested to offer an 
opinion as to:

(a).  Does the veteran have a mental 
disorder?  If so, state the diagnosis 
or diagnoses.

(b).  If the examiner finds that the 
veteran has a mental disorder, did 
such disorder have its onset during 
her period of active service from 
April 28, 1987 to April 27, 1990, or 
was it caused by any incident that 
occurred during such active service?

(c).  Did a mental disorder exist 
prior to the veteran's period of 
active duty from April 28, 1987 to 
April 27, 1990?  If so, state (if 
possible) the approximate date of 
onset of such disorder.

(d).  If a mental disorder preexisted 
the veteran's period of active duty, 
did the disorder increase in 
disability during such period of 
active duty?  In answering this 
question, the examiner is asked to 
specify whether the veteran sustained 
temporary or intermittent symptoms 
resulting from service; or whether 
there was a permanent worsening of the 
underlying pathology due to service, 
resulting in any current disability.

(e).  If a mental disorder increased 
in disability during service, was that 
increase due to the natural 
progression of the disease?

(f).  If the examiner finds that a 
mental disorder did not exist prior to 
the veteran's period of active duty 
from April 28, 1987 to April 27, 1990, 
is it as least as likely as not (i.e., 
50 percent or more probability) that 
such disorder had its onset during 
service, or was it caused by any 
incident that occurred during service?

(g).  If the examiner finds that a 
mental disorder is unrelated to 
service, then the examiner should 
opine whether the mental disorder is 
at least as likely as not (i.e., 50 
percent or more probability) due to 
the veteran's service-connected Bell's 
palsy, including whether the service-
connected Bell's palsy has aggravated 
any mental disorder.

The physician should set forth the 
complete rationale underlying any 
conclusions drawn or opinions expressed, 
to include, as appropriate, citation to 
specific evidence in the record, in a 
legible report.  A complete rationale 
should be given for all opinions and 
should be based on examination findings, 
historical records, and medical 
principles.

4.  To help avoid future remand, the RO 
must ensure that all requested actions 
have been accomplished (to the extent 
possible) in compliance with this 
REMAND.  If any action is not 
undertaken, or is taken in a deficient 
manner, then appropriate corrective 
action should be undertaken.  See 
Stegall v. West, 11 Vet. App. 268 
(1998).

5.  After completion of the foregoing and 
after undertaking any further development 
deemed warranted by the record (including 
a review of the March 2008 statement 
submitted by Dr. S.), the RO must 
readjudicate the veteran's claim on the 
merits.  If any determination remains 
adverse to the veteran, then she and her 
representative should be furnished with a 
Supplemental Statement of the Case and 
should be afforded a reasonable period of 
time within which to respond thereto.

The veteran has the right to submit additional evidence and 
argument on the matter or matters that the Board has 
remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).



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.  
See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007).



______________________________________________
DEBORAH W. SINGLETON
Veterans Law Judge, Board of Veterans' Appeals




 Department of Veterans Affairs