Citation Nr: 1324532 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 07-02 908 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a psychiatric disorder other than bipolar disorder (previously evaluated as hysterical neurosis). 2. Entitlement to increased rating for the service-connected bipolar disorder, rated as noncompensable prior to March 15, 2010, and as 10 percent disabling from that date. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from April 1978 to July 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued in October 2006 by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. Custody of the file has since been transferred to the RO in Waco, Texas. The appeal was certified to the Board as a claim of entitlement to service connection for a psychiatric disorder, claimed as depression. When the appeal came before the Board in February 2012 the Board noted the Veteran had been service-connected for a psychiatric disability (hysterical neurosis) since February 1987. However, there is no prohibition against a veteran being service-connected for more than one diagnosed psychiatric disorder; see Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) (noting that different psychiatric diagnoses may have symptoms that are not overlapping). The Board accordingly recharacterized the issue as entitlement to service connection for a disability other than hysterical neurosis. In February 2012 the Board denied entitlement to service connection for a psychiatric disorder other than hysterical neurosis. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In February 2013 the Court issued a Memorandum Decision finding that the Veteran's claim on appeal should have been construed as a claim for increased rating for the already service-connected hysterical neurosis. The Court thereupon vacated the Board's decision and returned the case to the Board. In April 2012, subsequent to the Board's decision and prior to the Memorandum Decision by the Court, the RO recharacterized the Veteran's service-connected psychiatric disability as bipolar disorder (previously evaluated as hysterical neurosis, disassociated-type) and assigned an increased rating of 10 percent effective from March 15, 2010. The Board has accordingly recharacterized the service-connection issue as shown on the title page, and has added the increased-rating issue that was identified by the Court as having been raised by the appeal. The Board's determination on the issue of entitlement to service connection for a psychiatric disorder other than bipolar disorder is set forth below. The issue of entitlement to increased rating for the service-connected bipolar disorder is remanded to the RO via the Appeals Management Center (AMC) in Washington, D.C.; VA will advise the Veteran when further action is required on her part. FINDINGS OF FACT 1. The Veteran is service-connected for bipolar disorder, previously characterized as hysterical neurosis. 2. The Veteran does not have an acquired psychiatric disorder other than hysterical neurosis/bipolar disorder that is etiologically related to active service. CONCLUSION OF LAW An acquired psychiatric disorder other than hysterical neurosis/bipolar disorder was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Complete notification, to include the disability-rating and effective date elements of a service-connection claim, was provided to the Veteran by letter in June 2006, and the Veteran had ample opportunity to respond prior to issuance of the October 2006 rating decision on appeal. At any rate, the Veteran has not asserted prejudice in regard to any error in the timing or content of notice provided. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran's service treatment records (STRs) are of record, as are the Veteran's post-service Social Security Administration (SSA) records and treatment records from those VA providers identified by the Veteran as potentially having relevant treatment records. The RO has made exhaustive attempts to obtain other post-service treatment records from various military and private hospitals under a number of different patient names, all unavailing, and in those cases appropriate statements of nonavailability have been procured regarding Federal hospitals and the Veteran has been advised of those private providers who were unresponsive. The Veteran has also been afforded appropriate VA examination in regard to her claim for service connection. The Board remanded the case in March 2010 for medical examination to determine if the Veteran has a psychiatric disorder, however diagnosed, is etiologically related to service. The Veteran's was examined in May 2010, and the same examiner issued an addendum opinion in January 2011 after reviewing the claims file. The Veteran's attorney has argued to the Court that the Board failed to ensure compliance with its March 2010 remand because the January 2011 opinion was a review opinion, not an actual medical examination. However, as explained above, the physician who issued the review opinion in January 2011 had in fact examined the Veteran in May 2010. Thus, the original examination report and the addendum report represent a competent and probative report by a single examiner that the Board finds to be in substantial compliance with the instructions articulated in the Board's March 2010 remand. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The attorney also complained that previous VA examinations provided to the Veteran have been inadequate because the examiners had not considered whether the Veteran's service-connected disabilities (bipolar disorder, residuals of left knee disorder and hemorrhoids) had aggravated her nonservice-connected traumatic brain injury (TBI). The Board disagrees. Residuals of TBI are evaluated as a neurological disorder under 38 C.F.R. § 4.124a, Diagnostic Code 8045, not as a psychiatric disorder under 38 C.F.R. § 4.130. Thus, VA mental health examiners have had no reason to provide an opinion as to whether service-connected medical and physical disabilities had aggravated a nonservice-connected neurological condition. At any rate, service connection for "brain damage" was specifically denied in a rating decision in June 2005; the issue of entitlement to service connection for TBI as secondary to one or more service-connected disabilities has not been adjudicated by the RO, is not reasonably raised by the issue on appeal, and is accordingly not before the Board. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Applicable Laws and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Certain chronic disabilities, such as a psychosis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of service connection there must generally be: medical evidence of a current disability; medical evidence, or in some cases lay evidence, of in-service occurrence or aggravation of a disease or injury; and, medical evidence of a nexus between an in-service disease or injury and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor involves consideration of whether the opinion is supported by a reasoned analysis. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence and Analysis The Board noted in its March 2011 remand that the Veteran is already service-connected for a psychiatric disorder (hysterical neurosis, disassociated-type). That illness, in part, was the reason for the Veteran's discharge from service in July 1979 after serving slightly more than one year. Service treatment records (STRs) show that in December 1978, while undergoing treatment at Letterman Army Medical Center (AMC) for residuals of a motorcycle accident, the Veteran became incoherent and was clinically diagnosed with hysterical dissociative reaction. She appeared to return to her premorbid condition and was placed on convalescent leave, and was eventually returned to duty in January 1979. In April 1979 she was treated for another motorcycle accident, with possible concussion and mental confusion. In May 1979 she presented to the Letterman AMC emergency room in a disoriented state, unable to recognize her co-workers and also complaining of vague fears of physical threat. She underwent a Medical Evaluation Board (MEB) in May 1979 that noted current psychiatric diagnosis of hysterical neurosis, dissociative type, chronic, treated and improved, manifested by frequent episodes of alteration of identity with amnesia. The MEB recommended the Veteran be evaluated by a Physical Evaluation Board (PEB) for separation from service. A PEB in June 1979 duly recommended that the Veteran be medically discharged from service due to current psychiatric disability (hysterical neurosis, dissociative type, with moderate social and industrial impairment) and physical disability (anterior medial rotary instability of the left knee, mild). A rating decision in November 1979 granted service connection for hysterical neurosis, dissociative-type, and assigned an evaluation of 10 percent disabling effective from the day after the Veteran's discharge from service. In July 1981 the Veteran underwent a psychiatric examination for VA purposes at the Fifth Army General Hospital (she was at that time a civilian employee of the Army and also the dependant spouse of an active duty soldier). The Veteran narrated that she began experiencing dissociative episodes as a child. These episodes were repeated until she entered active duty, but she did not seek treatment or report the episodes. While on active duty she had dissociative episodes (as cited above in STRs) and was diagnosed with hysterical neurosis, dissociative type as well as post-concussive syndrome. Following discharge from service she continued to have amnesic episodes whenever confronted with intense situations (conflicts, fights, or confrontations) but with therapy the amnesic treatments were minimal, infrequent and did not impair her ability to work. The psychiatrist's impression was history of hysterical neurosis, dissociative type, existed prior to service and with good occupational and social adjustment. In May 1984 the RO discontinued the Veteran's benefit payments because she had repeatedly failed to report for VA examination. The Veteran had a VA psychiatric examination in February 1987 in which she reported a traumatic childhood and also reported history of psychiatric disorders on both her mother's and father's sides of the family. She also described having endured spousal abuse in two of her three previous marriages. She described psychiatric treatment since 1985 and history of several suicide attempts as well as wide mood swings. She also asserted she had voluntarily relinquished her VA disability benefits in 1982 because she was feeling good and did not feel entitled to such payment. The examiner performed a mental status examination (MSE) and noted observations in detail. The examiner diagnosed probable bipolar illness (Axis I) and cyclothymic personality with no evidence of any current dissociative or hysterical neurosis (Axis II). As a result of the VA examination above the RO issued a rating decision in April 1987 that reduced the evaluation of the Veteran's psychiatric disability, still characterized as dissociative-type hysterical neurosis, from 10 percent to 0 percent (noncompensable) effective from the date of the examination. The noncompensable disability evaluation has been continued on several subsequent rating decisions, most recently in June 2005, and is not an issue on appeal before the Board. The Veteran had a motor vehicle accident in March 1987 when the car in which she was riding was hit head-on by a drunk driver. She was treated initially at Baptist Hospital and was later transferred to Biloxi VA Medical Center (VAMC) for domiciliary care. Extensive treatment notes are of record and show closed head injury with secondary dementia (see VA medical certificate in July 1987). The Veteran was treated in a VA behavioral medication/cognitive rehabilitation group, along with other patients who had experienced head trauma or stroke, due to her symptoms of behavioral outbursts and communication deficits; her symptoms were variously characterized as depression, anxiety or posttraumatic stress disorder (PTSD). In May 1988 the Veteran submitted a request that she be service-connected for PTSD, which she asserted was a result of the accident in 1987. Psychiatric examination was scheduled in November 1988 but the Veteran failed to report for examination. The RO issued a rating decision in December 1988 that the claim was being denied for failure to prosecute the claim (i.e., failure to report for examination). The Veteran had a VA psychiatric examination in April 1990 in which she cited the accident in 1987, resulting in a near-death experience with extensive physical injuries and brain damage. The examiner performed an MSE and noted observations in detail, including the Veteran's account of nightmares about the automobile accident. The examiner stated that the Veteran did not have dissociative episodes anymore and that all of her present difficulties could be attributed to brain damage sustained in the car wreck. The examiner diagnosed dissociative-type hysterical neurosis by history, although none found on current examination; organic personality syndrome; and, PTSD. In July 1990 the RO issued a rating decision that continued the current noncompensable rating for dissociative-type hysterical neurosis and denied service connection for PTSD. The Veteran presented to the VA urgent care clinic (UCC) in February 2005 complaining of depression, PTSD and needing medications. The staff physician noted history of brain damage secondary to auto accident 17 years before and depression for the past 4-5 months; the physician's impression was depression. A rating decision in June 2005 denied service connection for brain damage, based on a conclusion that the Veteran's brain damage was from an auto accident in 1987 after discharge from service. The same rating decision continued a current noncompensable rating for dissociative-type hysterical neurosis. A VA home-based primary care (HBPC) evaluation, prepared by a nurse practitioner (NP) and dated in October 2005, notes diagnosis of depressive disorder. A VA outpatient treatment note dated in February 2006 also notes provisional diagnosis of depressive disorder. Thereafter, in May 2006, the Veteran submitted the instant claim on appeal, asserting entitlement to service connection specifically for depression. The Veteran had a VA psychiatric examination in June 2006. The examiner noted the Veteran was not a reliable historian, having by her admission no memory prior to 1978. She reported history of a motorcycle accident in service in which she injured her left knee and also reported being in a head-on collision with a drunk driver, which she erroneously asserted had happened in service (as noted above, that accident happened in 1987). The examiner performed an MSE and noted observations in detail. The examiner diagnosed cognitive disorder not otherwise specified (NOS) and dysthymic disorder. The examiner stated that cognitive disorder and dysthymic disorder are separate chronic conditions but did not provide an opinion regarding the etiology of either disorder. The Veteran submitted a Statement in Support of Claim in June 2006 in which she asserted she was currently depressed because she was unable to work, had lost her home and possessions, and had no prospects for the future. A VA HBPC treatment note in June 2006 shows depressive symptoms associated with financial problems and lack of employment. In July 2006 her depressive symptoms had worsened and she was discharged from the HBPC program to continue care in the VA community-based outpatient clinic (CBOC). Her discharge from HBPC notes primary diagnosis of chronic brain damage and several secondary diagnoses including depressive disorder. The Veteran had an initial VA mental health clinic (MHC) evaluation in July 2006 in which she reported having had mood swings even before the automobile accident; she reported her mother was on medication for bipolar disorder and her brother also had psychiatric problems. The clinician, a nurse, performed an MSE and noted observations in detail. The clinician diagnosed mood disorder NOS. Thereafter, VA MHC notes dating from July-September 2006, written by a psychologist, show treatment for personality change due to traumatic brain injury (TBI), combined type (labile, disinhabited, aggressive); depressive disorder NOS; and, cognitive disorder NOS. Although the attending psychologist did not provide an etiology for the diagnosed disorders, review of the treatment notes indicates the Veteran's current psychiatric disorder was attributed to the residuals of her motor vehicle accident in March 1987, which had caused the TBI and resultant cognitive impairment. Also, treatment notes show the Veteran attributed her history of depressed mood to multiple psychosocial factors such as inability to drive, lack of friends and social life, financial problems and unemployment, none of which are related to service. In October 2006 the RO issued the rating decision on appeal, denying service connection for depression. The rating decision notified the Veteran that although depressive disorder had been diagnosed after service there was no evidence showing the disorder occurred in or was caused by service. In her substantive appeal, received in January 2007, the Veteran asserted she had an awful childhood due to a bipolar mother. She had come to understand that her period of service, with exposure to authority figures, triggered her latent childhood depression. The Veteran received 10 days of inpatient treatment at Timberlawn Mental Health System during the period May-June 2009. The discharge diagnosis was bipolar disorder I. The Veteran underwent a three-day neuropsychological and extended vocational evaluation in October 2009, performed by psychologist Dr. Jack G. Dial for the purpose of evaluating the Veteran's intellectual, sensorimotor and emotional functioning for the purpose of maximizing her employment options. The Veteran endorsed a history of depression since childhood. Her primary current disability was visual impairment secondary to TBI suffered in 1987. Dr. Dial administered a battery of interviews and psychological tests and noted observations in detail. Dr. Dial diagnosed cognitive disorder NOS, bipolar disorder NOS and alcohol and polysubstance dependence, both in sustained full remission. The Veteran had a VA examination in May 2010, performed by a psychologist who reviewed the Veteran's VA medical record and narrated her psychiatric history in detail. During interview the Veteran endorsed a family history of bipolar disorder, a childhood significant for abuse and a suicide attempt prior to service. The Veteran endorsed nightmares related not to service but rather to her abusive mother. The examiner performed an MSE and noted observations in detail. The examiner diagnosed current bipolar disorder NOS and polysubstance dependence in sustainful remission. The Veteran had a VA review examination in January 2011, performed by the same VA psychologist who had examined the Veteran in May 2010. The psychologist stated he had not diagnosed current hysterical neurosis because such diagnosis was no longer recognized in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association; however, the Veteran's current bipolar disorder NOS is a manifestation of her service-connected hysterical neurosis, dissociated. The examiner/reviewer stated that the file showed the Veteran had confided to a number of examiners, including the present reviewer, that her abuse experiences and mental health problems in response to that abuse (and possibly in response to a developing bipolar disorder) had started many years before active service. There was also a very strong history of psychiatric problems in her family. Dissociative episodes began in childhood and continued in service, with depressive symptoms and mood swings after service. For these reasons, the reviewer considered the Veteran's mental health issue to be one of bipolar disorder that began manifesting itself in childhood; there was no evidence that the preexisting mental disorder was aggravated by service, since her symptoms were at least as severe prior to entrance into service. In sum, based on the Veteran's own statements to the reviewer and her statements to other clinical providers of record, the reviewer disagreed with the Veteran being service-connected for any mental disorder. If service connection were to be continued, the diagnosis for the disability should be changed to bipolar disorder NOS as the more modern and appropriate classification for the Veteran's documented symptom history. The Veteran's current VA active/inactive problems list includes cognitive disorder NOS, bipolar disorder NOS, chronic PTSD and depressive disorder NOS. A recent VA mental health clinic (MHC) note in April 2011 reflected concurrent diagnoses of bipolar disorder and chronic PTSD. As noted by a VA psychiatrist in October 2010, the Veteran has a "complex psychiatric history." Review of the file shows the Veteran has been diagnosed or assessed over time with numerous psychiatric disorders in addition to the service-connected bipolar disorder; these include organic personality syndrome, PTSD, cognitive disorder NOS, mood disorder NOS, dysthymic disorder, depression, depressive disorder NOS and major depressive disorder (MDD). As noted in the Introduction, there is no prohibition against a veteran being service-connected for more than one diagnosed psychiatric disorder; see Amberman , 570 F.3d 1377, 1381. The Veteran has shown a number of diagnosed psychiatric disorders other than bipolar disorder, and to that extent the first element of service connection - evidence of a claimed disability - is met. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). In this case there is no competent medical opinion of record associating a psychiatric disorder other than bipolar disorder to service. In fact, the VA review opinion expressed an opinion that the Veteran does not have a current psychiatric disorder, however diagnosed, that is due to service, to include the already service-connected bipolar disorder. To the degree that clinical evidence ascribes the Veteran's current cognitive and depressive symptoms to any particular etiology, those symptoms are attributed to the post-service TBI in 1987 or to the Veteran's traumatic childhood; no medical opinion attributes her symptoms to service. The Board notes the opinion of the VA examiner that the Veteran should not be service-connected for any psychiatric disability, to include bipolar disorder, but the propriety of service connection is not an issue before the Board. Further, the Veteran has been service-connected for hysterical reaction since 1987; service connection for any disability that has been in effect for 10 or more years will not be severed, except upon a showing that the original grant was based on fraud or it is clearly shown from military records that the person concerned did not have the requisite service or character of discharge. See 38 C.F.R. § 3.957. Similarly, the examiner stated that the Veteran's bipolar disorder preexisted service and was not aggravated during service, but since the Veteran is already service-connected for that disorder the question of preexisting disorder, and aggravation thereof in service, is not relevant to the issue on appeal. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence above the Board has considered the evidence of record in the form of her correspondence to VA and her assertions to various medical providers. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Accordingly, the Veteran is competent to report psychiatric symptoms before, during and after service. However, the Veteran as a layperson is not competent to provide an opinion regarding a question as complex as the diagnosis and etiology of a psychiatric disorder. Kahana, 24 Vet. App. 428. Rather, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). As explained above, the competent and uncontroverted medical opinion of record shows the Veteran does not have a psychiatric disorder other than bipolar disorder that is etiologically related to service. The findings of a physician are medical conclusions that the Board cannot ignore or disregard. Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board also finds the VA examiner, who also authored the addendum opinion, was fully informed of the facts and provided a fully-articulated opinion supported by clinical rationale. The opinion is accordingly probative under the criteria of Nieves-Rodriguez. It is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). As explained above, competent and uncontroverted medical opinion of record shows the Veteran does not have a psychiatric disorder other than hysterical neurosis/bipolar disorder that is arguably related to service. In sum, the Board has found the Veteran does not have an acquired psychiatric disorder other than hysterical neurosis/bipolar disorder that is etiologically related to service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the evidence preponderates against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER Service connection for a psychiatric disorder other than hysterical neurosis/bipolar disorder is denied. REMAND The Court, in its Memorandum Decision, found that the Veteran's claim on appeal for service connection for depression should have been construed as a claim for higher rating for her service-connected bipolar disorder. The Board is bound by the findings of the Court. See Chisem v. Gober, 10 Vet. App. 526, 527-8 (1997) (under the "law of the case" doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case; the Board is therefore not free to do anything contrary to the Court's prior action with respect to the same claim). The Veteran's most recent psychiatric examination was performed in May 2010 (the subsequent addendum opinion by the same examiner, issued in January 2011, did not address current symptoms and is accordingly not relevant to the question of disability rating). An examination in May 2010 is too remote to serve as a basis for current evaluation, and the Board accordingly finds the Veteran should be afforded a new VA examination before the appeal is adjudicated. 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED to the RO for the following action: 1. The AMC/RO should send the Veteran a notice letter addressing the criteria for substantiating a claim for an increased rating for her service connected psychiatric disability, including what evidence the Veteran should submit and what evidence VA will make efforts to obtain. 2. The Veteran should be afforded an examination by a VA examiner qualified to provide an opinion regarding the current severity of her service-connected bipolar disorder. The claims folder must be made available to and reviewed by the examiner, and any indicated diagnostic studies should be performed. In addition to dictating objective test results, the examiner's report should fully describe the effects of the Veteran's bipolar disorder on her occupational functioning and daily activities. The examiner should provide a complete rationale for all opinions provided, and the RO should ensure that the examiner provides all information required for rating purposes. 3. The RO should also undertake any other development it determines to be warranted. 4. Then, the RO should readjudicate the issue on appeal (i.e., entitlement to a compensable evaluation for bipolar disorder prior to March 15, 2010, and to an evaluation higher than 10 percent from that date). If the benefit sought on appeal is not granted to the Veteran's satisfaction, the RO should furnish to the Veteran and her representative a supplemental statement of the case and afford them the requisite opportunity to respond before the case is returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. 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). 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. 2012). ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs