Citation Nr: 1324926 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 09-21 232 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a kidney disorder. 3. Entitlement to service connection for a bladder disorder. 4. Entitlement to service connection for a bilateral foot disorder. 5. Entitlement to a disability rating in excess of 30 percent for service-connected status-post hysterectomy with history of hysteroscopy. 6. Entitlement to a disability rating in excess of 30 percent for service-connected irritable bowel syndrome. 7. Entitlement to an initial disability rating in excess of 10 percent for service-connected bilateral otitis externa. 8. Entitlement to an initial compensable disability rating for service-connected residuals of a nasal fracture. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD N. L. Northcutt, Counsel INTRODUCTION The Veteran served on active duty from April 2006 to November 2007. These matters come before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) on appeal of rating decisions issued in June 2008, November 2008, July 2010, and February 2012 by the Regional Office (RO) in Salt Lake City, Utah. The June 2008 rating decision denied, in relevant part, service connection for foot, kidney, and bladder disorders, as well as service connection for the residuals of a nasal fracture. The November 2008 rating decision denied service connection for PTSD. The July 2010 rating decision (associated with the Veteran's Virtual VA claims file) in relevant part, granted service connection for bilateral otitis externa and assigned an initial noncompensable disability rating; granted a 30 percent rating for service-connected irritable bowel syndrome; and denied an increased rating for service-connected hysterectomy residuals. The February 2012 rating decision granted service connection for nasal fracture residuals and assigned a noncompensable initial disability rating. With regard to the Veteran's service connection claim for a psychiatric disorder, the Board acknowledges that the Veteran has specifically sought service connection for the psychiatric disorder of PTSD, as she made clear during her Board hearing, and the RO has accordingly adjudicated a claim for service connection for PTSD. Nevertheless, as it would be more beneficial to the Veteran to broadly construe this claim, the Board has rephrased the issue on appeal as one seeking service connection for a psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (instructing that service connection claims for PTSD should be construed broadly to encompass any mental disorder that may be reasonably encompassed by the claimant's description of the claim, reported symptoms, and other information of record). Furthermore, the Board acknowledges that the RO has deemed the Veteran's currently-diagnosed somatization disorder to be service-connected for VA treatment purposes only, as reflected in a July 2010 rating decision virtually associated with her claims file. However, as service connection for this psychiatric disorder is not in effect, the issue of service connection for a psychiatric disorder encompasses consideration of her currently-diagnosed somatization disorder/ undifferentiated somatoform disorder. With regard to the Veteran's service connection claims on appeal, the Veteran testified at a Board hearing conducted by the undersigned Veterans Law Judge in October 2009. A transcript of those proceedings has been associated with the Veteran's claims file. In May 2010, the Board remanded these service connection claims for further development, which has been completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that if the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance). Thereafter, the RO readjudicated these service connection claims in both a rating decision and supplemental statement of the case, which were issued in February 2012. As the RO granted service connection for the residuals of a nasal fracture in the February 2012 rating decision, the benefit sought has been granted, and this service connection claim is no longer in appellate status. However, the Veteran did voice her disagreement with the assigned noncompensable rating for her service-connected nasal fracture residuals and perfected this claim for appeal. Accordingly, this initial increased rating claim is before the Board. Additionally, she has perfected an appeal of the initial increased rating claim for bilateral otitis externa and of the increased rating claims for hysterectomy residuals and irritable bowel syndrome. When perfecting her appeal for these increased rating claims by submitting a VA Form 9 in May 2012, the Veteran requested to participate in a Board hearing conducted at the RO, and she reiterated this same request in subsequently submitted VA Forms 9. (Although it appears that the May 2012 VA Form 9 is currently associated with a temporary claims file located at the RO, correspondence between the Board and RO confirmed that the Veteran did indeed request a Board hearing at the RO in this VA Form 9.) Accordingly, these increased rating claims must be remanded so that she may be scheduled to participate her requested hearing. Additionally, the Board finds that further development is required with regard to the Veteran's service connection claims for kidney, bladder, and bilateral foot disorders. Accordingly, the Veteran's service connection claims for kidney, bladder, and bilateral foot disorders; and increased rating claims for hysterectomy residuals, irritable bowel syndrome, bilateral otitis externa, and nasal fracture residuals; are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDINGS OF FACT 1. The Veteran exhibited and was treated for psychiatric symptoms during service. 2. The Veteran has received continual psychiatric care since her discharge from service. 3. A probative VA medical opinion relates the onset of her currently-diagnosed psychotic disorder and undifferentiated somatoform disorder to service. CONCLUSION OF LAW The criteria for service connection for a service-related psychiatric disorder, identified as a psychotic disorder and an undifferentiated somatoform disorder, have been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Because this decision constitutes a complete grant of the benefit sought on appeal, namely service connection for a psychiatric disorder, no further discussion of the notice and assistance duties is necessary. Service Connection Claim The Veteran contends that she developed a psychiatric disorder, which she characterizes as PTSD, as the result of her traumatic experiences stemming from her in-service medical care. Specifically, the Veteran asserts that the delay in diagnosing and treating the source of her chronic abdominal pain, namely abdominal adhesions and a fibroid uterus, caused her significant mental distress, which she analogizes to torture. Moreover, she asserts that her medical records were altered, as she has identified numerous inconsistencies and anachronistic entries. She further asserts that rather than properly acknowledge and treat her medical problems in service, or give her a related medical discharge, her treating physicians and commanding officers conspired to discharge her from service on the basis of a personality disorder. In seeking VA disability compensation, a veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with active service in the Armed Forces, or if preexisting such service, was aggravated therein. Establishing direct service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The Veteran reports that she did not experience any psychiatric symptoms prior to entering service, and none were reported by the Veteran during pre-induction medical history reports completed in June and July of 2004 or assessed during a July 2004 medical examination. Indeed, the chronology outlined in the Veteran's voluminous service treatment records reflects a parallel progression between her psychiatric symptoms and her chronic abdominal pain. In October 2006, when seeking treatment for abdominal pain and menstrual irregularities, the Veteran reported experiencing significant stress and impaired concentration. She reported that her marital-related financial problems and excessive duties assigned by her unit were exacerbating her stress level. During another episode of abdominal pain treatment in November 2006, the Veteran reported experiencing several current life stressors and voiced paranoid ideation regarding her commanding officers, who she believed were not adequately accommodating her need to attend medical and legal appointments. At this time, the Veteran was diagnosed with an adjustment disorder with a depressed mood. A January 2007 service treatment record reflects that the Veteran, who was "well known" to both the emergent care and obstetric/gynecological hospital departments, was again seeking treatment for her chronic abdominal pain. The treating physician noted that due to her affect and observation of multiple prior social problems, a referral to the psychiatric department was deemed most prudent. A February 2007 service treatment record notes that the Veteran was seen for the sixty-second time in the prior 12 months at this hospital for complaints of chronic abdominal pain. The physician noted that the Veteran had undergone extensive workups to determine the etiology of her abdominal pain, which all revealed negative results, and that the Veteran had insisted on being prescribed narcotic pain relievers during prior appointments. The physician noted a query as to whether the Veteran's frequent presentations had an underlying secondary gain motivation. In February 2007, the Veteran sought emergent care at a private German hospital for abdominal pain (the Veteran was stationed in Germany throughout her period of service). While multiple diagnostic workups included positive findings of bacteruria, erythrocyturia, and ascending pyelitis were noted, the treatment report notes that no conclusive pathological finding for the Veteran's pain was discovered, although a notation in the report indicates that the source of her pain may have been suspected to be the result of abdominal adhesions. In April 2007, the Veteran sought a medical profile from her treatment providers after being advised by her unit to do so. The Veteran reported experiencing feelings of hopelessness regarding her illness and the inability to determine a related etiology. The treating provider noted that after conferring with a member of the psychology department, he learned that the psychology department as a whole believed that the Veteran had a personality disorder, which would be grounds for separation from service. An assessment of a personality disorder was noted. In May 2007, the Veteran underwent surgery at a private German hospital in which her uterus and Fallopian tubes were removed (hysterectomy and bilateral salpingectomy) and her significant adhesions were lysed (adhesiolysis). The operative report reflects that the mid-abdominal region pertaining to the small pelvis had massive adhesions, as well as dense adhesions of the bladder to the uterus wall. Additionally, the Veteran's uterus was noted to contain fibroids, resulting in a post-operative diagnosis of myomatous uterus. Subsequent service treatment records reflect the Veteran's complaints of experiencing continuing abdominal pain, with the Veteran exhibiting rambling, tangential speech in June 2007 and statements that those who diagnosed her with a personality disorder were working against her in July 2007. The Veteran was advised that she would be administratively separated from service on the basis of her diagnosed personality disorder in July 2007, and later that same month, the Veteran was escorted to emergent care for "emotional problems" by several service members, including her squadron leader. An assessment of a personality disorder was noted. The Veteran completed a medical history questionnaire in August 2007, at which time she reported having experienced loss or memory or amnesia, or neurological symptoms; frequent trouble sleeping; and having received counseling. In a corresponding medical examination report, the Veteran was assessed as psychiatrically sound. The Veteran's discharge from service on the basis of a personality disorder became effective in November 2007. Subsequent post-service VA treatment records reflect her ongoing psychiatric treatment, with definitive Axis I diagnoses including an adjustment disorder with mixed anxiety and depressed mood; an adjustment disorder with mixed disturbance of emotions and conduct; a psychotic disorder, not otherwise specified; a somatization disorder; and an undifferentiated somatoform disorder. (Earlier in the Veteran's treatment, treatment providers included several other non-definitive Axis I diagnoses of potential psychiatric disorders that should be "ruled out," including PTSD and bipolar disorder.) Additionally, several treatment records note the presence of personality disorder traits, or Axis II diagnoses, including Cluster B, paranoid, and borderline personality traits. The only medical opinion of record addressing the potential relationship between any of the Veteran's currently-diagnosed psychiatric disorders and service was authored by the Veteran's treating VA psychologist in July 2010. (The record has been associated with the Veteran's virtual claims file.) This opinion was predicated on a detailed and comprehensive psychological evaluation, which included a summation of the Veteran's social, medical, and military history, and incorporated the findings of two other evaluations performed by the VA psychology department. Additionally, the evaluating VA psychologist performed relevant diagnostic testing during the evaluation and rendered Axis I diagnoses of a psychotic disorder, not otherwise specified, and an undifferentiated somatoform disorder. With regard to the etiology of these psychiatric disorders, the VA psychologist related their onset to service. In support of this opinion, the psychologist stated that the Veteran's in-service physical health complaints, some with a known etiology and others having a delusional quality, led to physical limitations and recurrent requests for medical care during service, limiting her ability to effectively function in service. Moreover, her incipient developing paranoia further complicated her ability to function and caused her to question the integrity of her medical care, which in turn led to her seeking further medical treatment from non-military treatment providers. The Veteran's resulting impaired military performance in turn led to her disfavor by her military supervisors, furthering her paranoid ideation. The psychologist opined that the Veteran's in-service behavior was not a manifestation of a personality disorder, but rather was an expression of her complicated physical health concerns and a developing psychotic disorder. Moreover, the psychologist noted that the Veteran's development of this psychotic disorder during service while in her mid-thirties was consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, which states that females typically develop these types of disorders later in life than men, with the average age of onset from the mid-twenties to the mid-thirties. Moreover, he noted that up to 10 percent of women develop these disorders after the age of 40. VA treatment records created after this 2010 opinion was rendered continue to reflect the Veteran's current psychiatric diagnoses as including a psychotic disorder, not otherwise specified, and a somatization disorder (a more specific form of an undifferentiated somatoform disorder). At the outset of the analysis of this claim, the Board acknowledges that personality disorders are not diseases or injuries eligible for service connection, within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). However, in the instant case, the positive medical nexus opinion relates diagnosed psychiatric disorders other than personality disorders to service, which are eligible for service connection. As chronicled above and addressed in the 2010 medical opinion, the Veteran exhibited psychiatric symptoms and received psychiatric treatment during service, as reflected by her diagnoses of an adjustment and personality disorder and her referral for psychiatric treatment. Moreover, she has received ongoing psychiatric treatment since service for her various currently-diagnosed psychiatric disorders, as evidenced in the voluminous VA treatment records associated with her claims file. Thus, the evidence of record establishes both an in-service incurrence of a psychiatric disorder and a currently-diagnosed psychiatric disorder, thereby meeting the requirements of the first two elements of service connection. As such, a nexus to service is required to establish service connection. As determining the onset and etiology of a psychiatric disorder is a matter requiring medical expertise, the Veteran's assertions of causation cannot serve to link her current psychiatric state to service, as she has not asserted, and the evidence does not suggest, that she has the requisite medical expertise to render such an opinion. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (holding that a lay person is not considered competent to testify regarding medically complex issues). Thus, a probative medical opinion is required. In that regard, the Board finds that the 2010 VA psychologist's opinion linking the Veteran's currently-diagnosed psychotic disorder and undifferentiated somatoform disorder to service is of great probative value and can therefore establish the requisite medical nexus to service. The opinion is unequivocally stated, premised on a thorough and accurate social, medical, and psychiatric history of the Veteran, and is supported by a detailed and well-reasoned rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that to have probative value, the opinion provider must be fully informed of the pertinent factual premises, provide a fully articulated opinion, and provide a supportive reasoned analysis). The opinion is also consistent with the medical evidence of record, which outlines a corollary development between the exacerbation of her physical health in service and the onset and exacerbation of her psychiatric symptoms. Accordingly, a basis for granting service connection for a service-related psychiatric disorder, identified as a psychotic disorder and an undifferentiated somatoform disorder, has been presented, and service connection is warranted. ORDER Service connection for a psychotic disorder and an undifferentiated somatoform disorder is granted. REMAND With regard to the Veteran's service connection claims for kidney, bladder, and bilateral foot disorders, on which the undersigned Veterans Law Judge conducted a hearing in October 2009, the claims must be remanded to obtain the private treatment records identified by the Veteran in a statement and release form received by the RO in July 2012. In her submitted statement, the Veteran specifically asserts that treatment records from these identified private treatment providers should be obtained and considered, as the records reflect medical evidence relevant to her claims. Moreover, as the current medical evidence of record does not reflect any currently-diagnosed kidney or bladder disorders, or any foot disorders other than a post-service toe fracture or service-connected left ankle disability, these records are particularly germane to the appeal, as they may reflect current diagnoses of her claimed conditions. For that same purpose, the Veteran's recent, outstanding VA treatment records should also be obtained, which were last virtually associated with her claims file in December 2012. With regard to the Veteran's recently perfected appeal of her increased rating claims, the Veteran has requested to participate in a related Board hearing conducted at the RO, as reflected in several submitted VA Forms 9. Accordingly, she should be scheduled for such a hearing. Therefore, the case is REMANDED for the following action: 1. Schedule the Veteran for a Board hearing to be conducted in Salt Lake City, Utah, regarding the issues of entitlement to increased ratings for status-post hysterectomy with history of hysteroscopy, irritable bowel syndrome, chronic otitis media, and residuals of a nasal fracture. Notification of the scheduled hearing should be sent to the Veteran's latest address of record, and a copy of the notice should be associated with the Veteran's claims file. After the hearing is conducted, or if the Veteran withdraws the hearing request or fails to report for the scheduled hearing, the claims file should be returned to the Board, in accordance with appellate procedures. 2. Obtain the Veteran's VA treatment records from December 2012 to the present. 3. With any assistance necessary from the Veteran, obtain the treatment records from the following private treatment providers, identified by the Veteran in a statement and release form received in July 2012, as follows: * Carbon Medical Service Association 305 Center, East Carbon, UT * Emery Medical Center 90 West Main Street Castle Dale, UT * Castle View Hospital Price, UT * Castle View Clinic Castle Dale, UT * East Carbon Clinic Sunnyside, UT * Provo Regional Hospital Make at least two documented attempts to obtain these private records, unless doing so would be futile. If the records are unavailable, inform the Veteran of their unavailability. 4. Then, review the claims file to ensure that all of the foregoing development has been completed, and arrange for any additional development indicated. Then, readjudicate the claims on appeal. If any of the benefits remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and her representative an appropriate period of time to respond. The case is to then be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs